unit 4 - ankle and foot

optimal ROM of great toe and first ray

60 degrees great toe dorsiflexion 20 degrees first ray (medial cuneiform/1st metatarsal) dorsiflexion 20 degrees first ray plantar flexion

prognosis for plantar fasciitis

80% report resolution of symptoms in one year, regardless of intervention (other data claims 14 months) typically a chronic problem no consensus on a gold standard for therapy

conservative measures for neural injury

Edema management •Gentle exercises •Compression •Ice will prevent swelling but will not get rid of swelling •Elevation Splinting and rest Improve mechanics, orthotics Protection Rehabilitation with remaining function when safe Regular evaluation Constantly re-evaluate

deltoid ligament sprain can be associated with...

avulsion fracture of tibia, avulsion fracture of medial malleolus, fracture of distal fibula, and syndesmosis injury

if the foot demonstrates a frontal plane deformity, what will likely also be observed?

compensation of some kind in the opposite direction of the deformity - so we want to support into the deformity, not out of •Varus is compensated with valgus •Valgus is compensated with varus the compensation is an attempt to get the entire plantar surface of the foot on the ground the compensation can be in amount of motion, or with altered timing of motion

Thompson's test is indicative of...

complete rupture of achilles tendon

presentation of interdigital nerve entrapment

compression of the interdigital nerves between the 2nd and 3rd and the 3rd and 4th metatarsal heads aggravated by push-off and direct palpation with forefoot pain rule out a more proximal lesion (double crush syndrome) mechanics of the foot may change (50% of individuals with an entrapment will have a secondary entrapment - so you've gotta look for other entrapments)

open and closed packed positions of the talocural joint

open-packed: 10 degrees plantar flexion, mid position inversion/eversion closed-packed: full dorsiflexion

vascularity behind and under the malleolus

poor

posterior tibial tendon is (sheathed / non-sheathed)

sheathed

purpose of foot orthotic

to place the foot in a position in which it is better capable of supporting itself

congenital vertical talus (CVT) - what is it? treatment? rigid or flexible deformity?

•Pediatric •Calcaneus is plantar flexed •Leads to rigid rocker-bottom flatfoot rigid deformity An irreducible and rigid dorsal dislocation of the navicular on the talus If the navicular is reducible on the lateral maximum, plantar flexion radiograph, it is deemed an oblique talus

lateral ankle sprain evaluation

(as pain allows) history visual inspection ROM (active before passive) strength isometric selective tissue tension testing neurological function palpation girth or volumetric measurement stability tests (will be of little value the first 4-5 days) •Ankle •Midfoot balance and kinesthetic awareness attempt to rule out: - fracture - midfoot or forefoot sprain - peroneus brevis involvement and styloid involvement - achilles tendon involvement Specific Tests •talar distraction (not commonly performed except with imaging) •anterior drawer - not valuable when acute •talar tilt •peroneal tendon assessment (isometric eversion and palpate tendons) •palpation of areas known to have involvement (e.g., sinus tarsi, talar dome, ATFL) •anterior tibiofibular stability testing (squeeze, external/internal rotation of ankle)

hallux valgus etiology

(bunion deformity) Associated with a congenital large metatarsal head Poor fitting shoes Excessive pronation Thought to be hereditary component

secondary problems to hallux valgus

(bunion deformity) neuroma, stress fractures, lesions to other metatarsals, sesamoid degeneration, Achilles tendon problems, corns, claw toes

treatment for hallux valgus

(bunion deformity) once you have it, it's hard to treat, but it does seem to be preventable by fixing excessive formation and eliminating poor-fitting shoes

turf toe (what is it? treatment?)

(hyperextension of the great toe) Sprain of the great toe (MTP) joint Treatment: treat sprain, immobilize toe; hard insert in shoe to limited great toe extension stress

common motion limitations post-ankle fracture

(this is why limitations are so important!!) •Less than 20 degrees dorsiflexion in open kinetic chain, less than 30 degrees in closed kinetic chain •Limited subtalar inversion/eversion •Limited plantar flexion to less than 50 degrees, but not as impactful as limited dorsiflexion

types of problems that should lead to assessment for orthotics

-Low Back Dysfunction -Pelvic Girdle Dysfunction -Hip Pain -Knee Pain -Patello-femoral Dysfunction -Shin Splints -Gait Disturbances -Heel Pain -Tarsal Tunnel Syndrome -Plantar Fasciitis -Posterior Tibialis Insufficiency -Achilles Tendinosus -Mechanical Lower Quarter Pain

test for peroneal tendon subluxation/dislocation

1. Spontaneous dislocation with slight DF. 2. Lightly resist PF and Eversion while gently manipulating the ankle in various positions.

2 rearfoot deformities

1. subtalar varus -when pt is in subtalar neutral, they demonstrate inversion of the calcaneus -typically compensate by everting (pronating) to bring the foot in contact with the floor 2. subtalar valgus -when pt is in subtalar neutral, they demonstrate eversion of the calcaneus -typically compensate by inverting (supinating) and internally rotating leg to bring the foot in contact with the floor

____% chance of experiencing heel pain over the lifetime

10% (most likely under-reported as many do not seek medical attention)

_____% of all running injuries involve achilles tendon

10-15%

_____% will re-rupture achilles tendon when not surgically repaired

10-35%

____% of problems at foot seeking medical intervention are plantar heel pain

15% (most likely under-reported as many do not seek medical attention)

extension limitations > flexion limitations indicates capsular pattern at the ____ MTP joints

1st

capsular pattern of the MTP joints

1st MTP = extension limitations > flexion limitations 2nd through 5th = flexion limitations > extension limitations

expected return to activity for grade I or mild grade II lateral ankle sprain

2-3 weeks

how long must the patient hold each position in the BESS test?

20 seconds

optimal ROM of foot in frontal plane

25 degrees forefoot eversion 25 degrees forefoot inversion 10 degrees rearfoot eversion 20 degrees rearfoot inversion

flexion limitations > extension limitations indicates capsular pattern at the ____ MTP joints

2nd-5th

return to full activity ______ after peroneus longus tendon repair

3 months

ROM of the subtalar joint

30 degrees -1/3 of the range with eversion -2/3 of the range with inversion

presentation of acute achilles tendon rupture

30ish yo male or elderly person Rapid loading of the foot (4 to 8% strain) Instantaneous pop, may have no pain May have had previous glucocorticoid steroid injection or chronic steroid use. Anabolic steroids and prescription drugs such as fluoroquinolone (FQ) antibiotics can predispose

___% of lateral ankle sprain patients develop chronic ankle instability

40%

____% of ankle sprains lead to additional ankle sprains

40%

return to full activity post achilles tendon rupture repair is expected at what time?

5-6 months after surgery

optimal ROM of ankle in sagittal plane

50 degrees plantar flexion 20 degrees dorsiflexion

suggested max amount of rearfoot posting

6 degrees = 6 mm

suggested max amount of forefoot posting

6-7 degrees or 6-7 mm

cannot have normal gait without ___ at the great toe

60 degrees great toe dorsiflexion

what percentage of the population with ankle sprains receive PT?

;ess than 5%

presentation of subluxation of the cuboid

A probable common but poorly recognized condition Presents as lateral midfoot pain (sometimes ankle pain) Pressing on the plantar cuboid is painful and the plantar cuboid is more prominent Normal plantar / dorsal joint play is reduced Can occur with forefoot valgus

basset's ligament injury often coincides with...

ATFL injury impingement

CPGs for intervention during acute/protective motion phase and during progressive loading phase for lateral ankle sprains

Acute/protective motion phase: - WB: Clinicians should advise patients with acute lateral ankle sprains to use external supports and to progressively bear weight on the affected limb (type of support based on severity, phase of tissue healing, level of protection indicated, extent of pain and patient preference); immobilization ranging from semi-rigid bracing to below knee casting may be indicated - Manual: Clinicians should use manual therapy procedures within pain-free movement to reduce swelling, improve pain-free ankle and foot mobility, and normalize gait parameters in individuals with an acute lateral ankle sprain - Physical Agents: Cryotherapy: clinicians should use repeated intermittent applications of ice to reduce pain, decrease the need for pain medication, and improve WB following an acute ankle sprain (strong evidence); Diathermy: clinicians can utilize pulsating shortwave diathermy for reducing edema and gait deviations associated with acute ankle sprains. (weak evidence); Electrotherapy: moderate evidence both for and against the use of electrotherapy for the management of acute ankle sprains; Low-level laser therapy: moderate evidence both for and against for the management of acute ankle sprains; Ultrasound: clinicians should not use ultrasound for the management of acute ankle sprains - Ther ex: Clinicians should implement rehabilitation programs that include therapeutic exercises for patients with severe lateral ankle sprains Progressive loading/sensorimotor training phase: - Manual Therapy: Clinicians should include manual therapy procedures, such as graded joint mobilizations, manipulations, and non-weight-bearing and weight-bearing mobilization with movement, to improve ankle dorsiflexion, proprioception, and weight-bearing tolerance in patients recovering from a lateral ankle sprain - Ther ex and activities: Clinicians may include therapeutic exercises and activities, such as weight-bearing functional exercises and singlelimb balance activities using unstable surfaces, to improve mobility, strength, coordination, and postural control in the postacute period of rehabilitation for ankle sprains - Sport-related activity training: Clinicians can implement balance and sport-related activity training to reduce the risk for recurring ankle sprains in athletes

1 year follow-up post-ankle sprain, ____% of patients still experienced pain and subjective instability within a period of 3 years, as much as _____% of the patients reported at least 1 re-sprain

After 1 year of follow-up, 5-33% of patients still experienced pain and subjective instability Within a period of 3 years, as much as 34% of the patients reported at least 1 re-sprain

rehab post-peroneus longus tendon repair

Air cast or ankle braces are used with peroneal tendon injuries Semi-rigid to rigid Orthotics to relieve stress to the tendon Rehabilitation after 4 weeks of immobilization Eccentric exercise, balance activities Return to full activity at 3 months

forefoot allows what motions?

Allows flexion and extension of the metatarsals, supination and pronation of the first and fifth rays

high ankle sprain is a sprain of the...

Anterior tibiofibular ligament

two most common balance measures

BESS manual and star excursion test

hallux valgus (presentation, cause)

BUNION Varus/adducted position of metatarsal (greater than 15 degree angle with the 2nd metatarsal) •Valgus/abducted deviation of proximal phalanx Risk factors: genetic predisposition, pes planus, RA, CP, shoes with narrow toe box & high heel

management of hallux valgus

BUNION proper shoes orthotic (keep 1st metatarsal from drifting more medially) tape brace often surgery (Brace or taping do not lead to a change in the angle of the first metatarsal, which is the cause of the deformity)

causes of abnormal pronation

Can be a result of: -Early excessive pronation (pronated at heel strike) -Failure to resupinate in late stance phase of gait Intrinsic causes: -Rearfoot varus -Forefoot varus -Medial roll-off with avoidance of 1st MTP dorsiflexion -Posterior tibialis insufficiency -Limited ankle dorsiflexion (equinus) Extrinsic causes: -Rotational deformities of the thigh -Rotational deformities of the leg -Compensation to varus deformities of the lower extremity (genu varus, tibial varus) -Leg length discrepancies (may pronate on long leg side, supinatory position of short leg side)

midtarsal joint AKA...

Chopart's joint

talocrural joint consists of _____ arthrokinematically describe the plantarflexion and dorsiflexion arthrokinematically (open chain vs. closed chain)

Convex talus under concave mortise Open chain = convex talus moves on concave mortise -Dorsiflexion: Talus rolls anterior and slides posterior -Plantar flexion: Talus rolls posterior and slides anterior Closed chain = concave mortise moving over convex talus -Dorsiflexion: mortise rolls and slides anterior -Plantar flexion: mortise rolls and slides posterior Movement of fibula in cranial direction with dorsiflexion or eversion Movement of fibula caudally with plantar flexion or inversion

emerging therapy for plantar fasciitis

Correcting problems at the hip, knee, ankle, and foot (strength, endurance, ROM) Regenerative medicine

dorsiflexion is a _____ dorsiflexed is a ______ which one is a movement and which one is a position

Dorsiflexion is a motion Dorsiflexed is a position

presentation of high ankle sprain/syndesmosis injury

Dorsiflexion is limited and painful Diminished effectiveness of plantar flexors (displaced talus in plantar flexion) Rotation (abduction/adduction of talus) and dorsiflexion are painful Can have increased width of the mortise (if torn interosseous membrane) Can have bony avulsion

discuss mobilization vs. immobilization for lateral ankle sprain

Early mobilization has been the focus for management the past 10 to 20 years Prior to this, many ankle sprains were put in a cast for 3 to 4 weeks Current evidence suggests that ED intervention (rest, ice, compression, and elevation) leads to incomplete recovery Some studies suggest, immobilization for up to 2 weeks after injury (cast boot) followed by rehab may lead to improved outcomes

posterior tibial tendon insufficiency presentation (and differences at stages)

Early signs: -aching and swelling of the medial ankle and foot -tenderness along the distal medial leg and medial-plantar foot With progression: -heel valgus -forefoot abduction (too many toes sign) -collapse of the arch -pain shifts laterally as the disease progresses - pain in late stages is due to synovitis and joint strain in the ankle, subtalar, and midfoot joints -as the disease progresses the talus impinges on the distal fibula producing lateral ankle pain, impingement of the talus on the calcaneus at the posterior talar facet produces posterior pain stage 1: -tendon length normal, inflammation in the tendon/sheath, fluid in the tendon sheath, synovial proliferation -can have longitudinal split tears in the tendon stage 2: -tendon elongation, hind foot remains mobile but mildly deformed -degeneration of the tendon over several centimeters --> muscle adaptively changes --> adhesions around the tendon and the sheath --> tendon loses tensile strength stage 3: -tendon elongation, hind foot significantly deformed and stiff (stuck in abduction and calcaneal eversion)

etiology and treatment of plantar fasciitis

Etiology: •A chronic degenerative problem •Doubtful that a productive inflammatory process is involved Treatment: •Current treatment philosophy involves some form of irritating the tissue, not reducing inflammation •Steroid injections typically give less than favorable results •Surgery can give less than favorable results and release of the plantar fascia can lead to severe arthritic changes in the foot

mechanism of injury for deltoid ligament

Eversion is a common mechanism to injure the middle portion Lateral rotation of the foot can injure the anterior portion Over pronation can attenuate the ligament over time (such as with posterior tibialis tendon failure)

ankle joint stability supplied by ____ in dorsiflexion and plantar flexion

Excessive talar movement during inversion while the foot is plantar flexed, is retrained by the anterior talofibular ligamen In dorsiflexion, boney relationships, the calcaneofibular ligament and the posterior talofibular ligament restrain motion

things to rule out with suspected plantar fasciitis

Fat pad atrophy Proximal plantar fibroma Plantar facial rupture (bruising medial plantar foot) Tendinitis of the flexor hallucis longus, flexor digitorum longus, or both Heel pain syndrome (micro-tears of the plantar aponeurosis and fascia and intrinsic muscle that arises from the medial calcaneal tuberosity) •Periostitis of the medial calcaneal tuberosity •Bone spurs are usually deep to the tuberosity and are not thought to play a role Rheumatic disease Gout Neuritis / tarsal tunnel syndrome Bone pathology (tumor, etc.) Medial calcaneal nerve entrapment/injury Spring ligament, long or short plantar ligament sprain (midfoot sprain)

predisposing factors to inversion ankle sprains

Fatigue, low fitness level, slower running Dysfunction with static and dynamic balance Ankle dorsiflexion strength deficit Poor coordination, directional control Limited dorsiflexion range of motion

theory behind forefoot posting

Felt to hold the abnormal forefoot in a near-normal relationship to the rearfoot while on a supporting surface Used with forefoot valgus or varus Felt to reduce the need for rearfoot compensation Correct 60% of the abnormality •So if they have a 10 degree forefoot varus, we'll post about 6 degrees

most effective treatment for chronic ankle sprains

Few studies have researched the most effective method for rehabilitation of chronic ankle sprains Current evidence is that balance, perturbation training is most effective

indications for forefoot posting

Forefoot varus or valgus deformity Flexible medial arch insufficiency (navicular drop) Problems with excessive or abnormal motion during the propulsive phase of stance Lack of functional motion of the first MTP joint during propulsive phase of stance Can post forefoot if cannot post rearfoot enough

common complications with inversion ankle sprain

Fracture (fx), or avulsion fx of fibula Osteochondral fx of the talus (dome) Lateral process fx of the talus Peroneal or sural nerve injury (can develop Complex Regional Pain Syndrome) Anterior tibiofibular ligament (high ankle sprain) Syndesmosis sprain Syndesmosis tear Sinus Tarsi syndrome (impingement), cervical ligament Rapid inversion can also injure cervical ligament, now impinged between talus and calcaneus; check for tenderness in sinus tarsi Talocrural impingement (anterior displaced talus) Peroneal Tendon Involvement (strain, tear, avulsion) Cuboid dysfunction Fibular dysfunction Make sure fibular head moves normally Forefoot sprain If medial ankle involvement with an inversion sprain, then a severe sprain must be expected or a fracture Immediate (to a couple of hours) swelling indicates bleeding •Grade III injury •Fracture Ankle capsular tear can lead to impingement as scarring occurs •Capsule flips back in between talus and distal tibia and gets pinched between

grading system for ankle sprains

Grade I (microdamage): -no loss of motion -no ligamentous laxity -no ecchymosis (or minimal) -no or minimal point tenderness Grade II (little more damage): -some loss of function -decreased motion -may have a positive anterior drawer test (excessive anterior glide of talus) -negative talar tilt -ecchymosis (discoloration, bruising) -swelling -tenderness Grade III (complete tear): -nearly total loss of function -positive anterior drawer and talar tilt tests -diffuse swelling (swelling that came on immediately after injury) -ecchymosis -extreme tenderness

treatment of tarsal tunnel syndrome

High Tarsal Tunnel Syndrome •Rest and immobilization •Surgery Traditional Tarsal Tunnel Syndrome: •Correct biomechanics •Reduce irritability •Rehabilitation •Surgery Distal Tarsal Tunnel Syndrome: •Correct biomechanics •Reduce irritability •Rehabilitation •Surgery

treatment of midfoot/forefoot sprains

Ice, compression, elevation Taping, bracing (extending across mid tarsal joint) Manual therapy for dysfunctional cubiod, cuneiforms Orthotic or stainless steel innersole Balance, graded exercise

prognosis for high ankle sprain

If no widening of distal tib-fib joint, walking cast for 2 to 6 weeks Surgery if interosseous membrane is involved

PT for lateral ankle sprain

Immediate care: •Ice, compression, elevation, immobilization (horseshoe compression; wrap from the toes!) •If limping, should use crutches •Can WB as tolerated with CW •AROM (especially DF) •Isometric exercises (will help pump swelling out_ •Possibly manual therapy (posterior glide of talus, glides of cuboid) Extended care: •Taping or bracing for function and exercise (strong evidence) •Isometric and isotonic exercise •Closed chain exercise •Controlled ROM •Manual therapy (weak evidence) •Pool running, etc. (reduced WB activities) •Neuromuscular/Balance and Proprioception training, BAPs board, foam pad, mini-tramp, etc. (strong evidence) •Ice is used as long as beneficial, progress to contrast baths (expert opinion, no evidence)

prevention of medial tibial stress syndrome

Increase strength and endurance capabilities (soleus, posterior tibialis) •Posterior tibialis functions eccentrically to control pronation of the foot - improve eccentric function Correct faulty foot mechanics - control over-pronation Shoes that promote adequate shock attenuation/absorption Cross-training that takes load off the tibia Allow bone remodeling to "catch up" (rest periods) Avoid hard surfaces for running

insertional vs. non-insertional achilles tendinopathy

Insertional: issues where it attaches at calcaneous Non-insertional: issues usually around musculotendinous junction; sometimes mid-substance -Non-insertional has a better prognosis than insertional

where does achilles tendinitis occur?

Insertional: issues where it attaches at calcaneous Non-insertional: issues usually around musculotendinous junction; sometimes mid-substance -Non-insertional has a better prognosis than insertional

Graston technique

Instrument Assisted Soft Tissue Mobilization often used with tendonosis - just enough pressure so that it is tolerable but irritating the tendon to evoke the inflammatory response

examination of midfoot/forefoot sprains

Inversion / eversion of the midfoot on a stable ankle / rearfoot Plantar flexion / dorsiflexion of the midfoot Accessory motion testing Palpation Ottawa foot rule

if you are suspicious of a medial ankle sprain, you should rule out...

Involvement of the spring ligament (midfoot sprain) Posterior tibialis tendon injury (similar mechanism to deltoid sprain)

hallux rigidus (presentation, cause)

Lack of extension at the 1st MTP joint due to a dysfunction of the joint (trauma, pathology) Limited motion with both active and passive motion, regardless of position of the 1st ray

findings that may indicate benefit with orthotics

Limited ankle dorsiflexion ROM •With knee bent and straight Abnormal first ray position and limited mobility Windlass mechanism •If you dorsiflex the toes, and it does not create an arch, then it's doubtful that an orthotic will help them - particularly if it is a rigid foot Limited first MTP joint ROM Limited midfoot mobility Hip rotation ROM in sitting and prone (hip flexed and hip in neutral) Hip abductor and external rotator strength Hip flexor and hamstring length Abnormal subtalar neutral (rearfoot varus, valgus) Forefoot varus/valgus

lateral ankle sprain prevention

Limited evidence for a small decrease in risk: •Aircast braces •Ankle disk training (proprioception/balance board training) •Taping No data on stretching, increasing dorsiflexion, strengthening being of any benefit

exam for heel pain and Achilles pain

Look for other possible foot dysfunctions Measure dorsiflexion - will be limited MMT of gastrocnemius - will be weak Palpation •Palpable tenderness/thickening of the involved tendon, particularly in mid-substance of tendon *Royal London Hospital Test will be positive Arc Sign will be positive Thompson's test (only tells you if there's a complete rupture) •Squeeze calf, looking for foot to plantar flex Differentials: -Homan's sign not sensitive or specific (deep vein thrombosis), good historical data is needed -Calcaneal fracture: (should be particularly concerned if there is pain at the insertion site) -In a child or adolescent then suspect Sever's disease (growth plate near achilles tendon gets irritated)

describe the procedure of the BESS manual

Looking for person to have errors in different standing positions (Score = amount of errors) •An error is classified as: moving the hands off of the iliac crests, opening eyes, a step, stumble or fall, abduction or flexion of the hip beyond 30 degrees, lifting the forefoot or heel off test surface, remaining out of the proper testing position greater than 5 seconds Standing positions: double leg stance, single leg stance (on non-dominant foot - dominant defined as foot they would kick with), tandem stance (dominant in front of non-dominant) Two surfaces for each position: floor and foam pad Maintain each position for 20 sec Shoes off Hands on hips

Jogger's Foot AKA...

Medial Plantar Nerve Entrapment

movement of fibula with inversion

Movement of fibula caudally

movement of fibula with plantar flexion

Movement of fibula caudally

movement of fibula with dorsiflexion

Movement of fibula cranially

movement of fibula with eversion

Movement of fibula cranially

treatment of deep peroneal nerve entrapment

NSAIDs, cast or brace, surgical release

treatment for achilles tendon rupture

Non-surgical: -Cast: short leg cast in plantar flexion (with use of heel lift) for 8 weeks, followed by a 2.5 cm heel lift for 4 weeks (some will come to PT with boot on before 12 weeks) -10% to 35% will re-rupture when not surgically repaired -PT for ROM and strength at 12 weeks Surgical: -Posterior splint -Patient may begin ROM around 7 days (out of the splint) -PT for general conditioning and ROM may begin week 2 -Patient wears a splint and CW for 6 weeks -Postoperative immobilization for 4 to 10 weeks -Return to full activity is expected at 5 to 6 months 2-6 weeks -Transition to removable cast boot: If hinged, place in 20 degrees plantarflexion; not hinged (flat): 2-cm heel wedge to approximate 20 degrees plantarflexion -WBAT in boot; use crutches with boot until no pain or limpActive dorsiflexion to neutral, inversion/eversion below neutral, no resistance -Modalities to control swelling -Hip/knee exercises as appropriate -Hydrotherapy: NWB, adhere to motion restrictions -Wear boot all times except for bathing (NWB) or exercises 6-8 weeks -Removable cast boot at neutral; remove heel wedge -Wear boot all times except for bathing or exercises -WBAT in boot, wean off crutches -Dorsiflexion stretching, slowly -Graduated resistance exercises (open and closed kinetic chain as well as functional activities); Dual support heel raises -During supervised PT, start balance proprioceptive exercises, stationary bike, elliptical trainer in regular shoe -Hydrotherapy with underwater treadmill 8-12 weeks -Remove boot. 1-cm heel lift in shoe -Continue to progress ROM, strength, proprioception 12 weeks -Continue to progress ROM, strength, proprioception -Retrain strength, power, enduranceIncrease dynamic WB exercise, include plyometric training -Sport-specific retraining

normal excursion of the tibialis posterior

Normal excursion: 1.5 cm Any change in length can cause tearing - leads to tendon insufficiency

hallux limitus (presentation)

Normal hallux ROM in NWB, reduction of hallux ROM in WB •resulting in limited MTP joint dorsiflexion (extension) during propulsion phase of gait 1st ray needs to plantar flex 20 degrees to allow the MTP joint to extend (dorsiflex) the full 60 degrees need for optimal foot function •Toes have to extend during propulsion to activate the Windlass effect that locks the foot - If they can't do this, they'll come over either lateral or medial foot - often medial (puts callus on medial side of foot) - pushes great toe lateral (developing hallux valgus) •In hallux limitus, 1st ray is not plantar flexing, which means great toe can't extend

treatment for peroneal tendon subluxation/dislocation

Only treated if symptomatic Surgical intervention, followed by: -Cast immobilization for 2 weeks -Walker cast boot for 3 weeks -PT begins at 3 weeks

posterior impingement syndrome (what is it? treatment?)

Os trigonum causes crowding of the structures posterior to the ankle joint FHL tendon entrapment within the fibrous flexor sheath behind the medial malleolus patient will likely have surgery

Haglund deformity (what is it? treatment?)

Osteophyte on posterior calcaneus Treatment: -Can put pad around that deformity to take pressure off bc it might be the shoe rubbing on the osteophyte that is causing the pain -If thought to play a role in insertional tendinosis, then a portion of the os calcis is taken off surgically -If you catch it before it's well-formed bone, ultrasound may actually help

radiographic rules for the ankle and foot

Ottawa Ankle Rules: Pain in the malleolar region and any one of the following: •Bone tenderness along the distal posterior edge of the tibia or distal medial malleolus •Bone tenderness along the distal posterior edge of the fibular or distal lateral malleolus •Inability to weight bear, take 4 steps Ottawa Foot Rules: Pain in the midfoot area and any one of the following: •Bone tenderness at the base of the 5th metatarsal •Bone tenderness at the navicular •Inability to bear weight or take 4 steps Additional considerations: •Focal bone tenderness or visible deformity indicates the need for imaging •Gentle bending of long bone •Tuning fork - auscultation (muffled)

CPGs for examination of acute lateral ankle sprains and ankle instability

Outcome measures: -Clinicians should incorporate validated functional outcome measures, such as the Foot and Ankle Ability Measure and the Lower Extremity Functional Scale, as part of their examination - these should be utilized before and after interventions Activity limitation and participation restriction measures: -When evaluating a patient in the postacute period following a recent or recurring lateral ankle sprain, assessment of activity limitation, participation restriction, and symptom reproduction should include objective and reproducible measures, such as single-limb hop tests that assess performance with lateral movements, diagonal movements, and directional changes. Physical impairment measures: -When evaluating a patient with an acute or subacute lateral ankle sprain over an episode of care, assessment of impairment of body function should include objective and reproducible measures of ankle swelling, ankle range of motion, talar translation and inversion, and single-leg balance.

____ in gait is an etiologic factor in noninsertional achilles tendinitis

Over-pronation (particularly late pronation when it should be resupinating)

examination findings of a deltoid ligament sprain

Pain and possible laxity with eversion of the calcaneus (mid portion) Pain with external rotation of the talus (abduction of the foot) under the leg (anterior portion) Medial laxity with anterior drawer if anterior portion sprained (foot deviates laterally)

CPGs of diagnosis/examination of plantar fasciitis

Pain with palpation at proximal insertion of plantar fascia (medial heel) Medial heel pain with initial steps after inactivity Decreased talocrural dorsiflexion (AROM and PROM) Positive Windlass test Heel pain precipitated by a recent increase in WB activity Foot posture index often indicates excessive hindfoot eversion and midfoot pronation Negative tarsal tunnel tests (May also use a diagnostic ultrasound (aponeurosis thicker on imaging, degenerative process) - that's not in the CPGs though) Should rule out differentials when the individual's reported activity limitations or impairments of body function and structure are not consistent with plantar fasciitis Should utilize easily reproducible performance based measures of activity limitation and participation

examination for posterior tibial tendon insufficiency (in general and at different stages)

Patient is unable to stand on tiptoes - heel remains in valgus Foot is abducted - "too many toes sign" Can mimic a rupture of the spring ligament (which runs from sustentaculum tali to navicular) in pain location Palpate the PTT with resisted PF and Inversion to feel for integrity of tendon (healthy tendon should pop right into hand) stage 1: also rule out rheumatoid arthritis or variants

neuromuscular responses in people with frequent ankle sprains and what that means for treatment

People with frequent ankle sprains have inhibited neuromuscular responses, involving both inverters and everters Treatment: -Range of motion and strengthening exercise do not address the neuromuscular deficit (e.g., muscle inhibition) -Train neuromuscular responses through perturbation training

bony impingement syndromes - what is happening?

Periosteum has two layers: superficial fibrous layer and deep cambium layer -Cambium layer has osteogenic properties One bone repetitively striking another wears away the fibrous layer and stimulates the cambium layer to produce bone --> Leads to osteophytes (impingement spur)

pathway of the peroneus longus and brevis functions of each

Peroneus longus - goes to cuboid pulley and then goes to 1st metatarsal and 1st cuneiform - helps support 1st ray Peroneus brevis - goes to styloid process of fifth metatarsal Both assist in plantar flexion and eversion

what other motions happen at the foot and ankle with plantar flexion? with dorsiflexion?

Plantar flexion includes inversion, adduction Dorsiflexion includes eversion, abduction

risk factors for medial tibial stress syndrome

Poor foot biomechanics (odds ratio [OR] = 9.2) •WB greater on the medial side of the foot •High pressure at heel strike •Shorter time to peak heel rotation •Use of foot orthotics in younger athletes Low fitness level Smoking (OR = 6.5) - one study Previous history of stress fracture Previous history of MTSS Greater BMI Greater navicular drop Greater ankle plantar-flexion ROM Greater hip external-rotation ROM

Closed chain subtalar pronation/supination

Pronation: -knee flexion -tibia internally rotates -talus adducts and plantar flexes -plantarflexion of talus lowers navicular and thus lowers arch of foot -calcaneus everts Supination: -knee extension -tibia externally rotates -talus dorsiflexes and abducts -calcaneus inverts -raises arch

indications for rearfoot posting

Rearfoot varus deformity To create eversion ROM Early excessive pronation (heel strike with the foot already in or near-full pronation) To add additional posting if cannot post the forefoot enough to correct

Treatment for medial tibial stress syndrome

Responds to conservative treatment - main gist should be addressing the mechanics of the foot PT: •Manage as an over-use injury •Rest for up to 4 months in some cases ("relative rest") if severe •Ice and NSAID (phonophoresis/iontophoresis - no evidence for or against) •NWB activities (pool, body weight supported, bike, etc.) •Change duration and surface involved with training •Limit pronation/improve mechanics (taping, orthotic, manual therapy) •Shock absorbing foot wear •Core strengthening, eccentric LE exercise (calf) •Correct proximal and distal impairments •50% will improve in 3-weeks with orthotics to control pronation •Replace shoes frequently (300 miles) •Interventions recommended by some experts but no research: exercise, calf stretching, taping the leg (shin) •Some evidence that shock wave therapy does not help If symptoms persist, imaging and other tests for compartment syndrome or fracture are indicated •If repetitive episodes, fasciotomy is performed to reduce traction on periosteum •Cauterization of the periosteum (only 41% of athletes able to return to sports participation)

bursitis that may occur as a result of achilles tendinopathy

Retrocalcaneal bursa between the tendon and the calcaneus (Both the tuberosity and the bursa are involved with insertional tendinitis) - If pt is tender anterior to tendon, retrocalcaneal bursa may be inflamed Some people have a subcutaneous bursa just under the skin that could get irritated

different materials for orthotics and why you would use one over the other

Rigid orthotic for a hypermobile foot, support and an attempt to control motion to some degree Soft, pliable material for a rigid foot or a foot that needs soft support keeping the deformity (such as with rheumatoid arthritis)

bruised plantar surface with symptoms of midfoot/forefoot sprain, suspect...

Severe Midfoot/forefoot sprains Lisfranc's injury Dislocation and/or fracture

causes of a peroneal tendon subluxation/dislocation

Shallow groove, pes planus, severe rear foot valgus, or a lax superior peroneal retinaculum Can occur with recurrent lateral ankle sprains Can be associated with ankle instability and tears of the brevis tendon

parts of an orthotic and their functions

Shell: -flexible, semi-rigid, or rigid -what we build the orthotic around Posts: -to support the foot -forefoot, rearfoot -intrinsic (built into the shell) or extrinsic (added to the shell) Cutouts: -remove part of shell to take pressure off -first ray standard, bi-directional, metatarsal cuneiform Extensions: -covers on orthotics - keeps orthotic from sliding around in shoe -to the sulcus or end of toes Lifts: -to help with leg length discrepancy, to enhance DF

compartment syndromes of the leg

Signs and symptoms: •Paresthesia, neurological signs and symptoms in the foot •Vascular signs and symptoms in the leg/foot (e.g. diminished pulse, cold foot, muscle weakness, diminished sensation, swollen foot, swollen calf) •Need for immediate referral •History of trauma, over-use, symptoms with an activity pressure builds up in one of the compartments - leads to compression on nerves and vasculature common area: peroneal nerve at the fibular head can be a medical emergency increased pressure due to swelling or compromised/ insufficient space in a fascial compartment diagnosed by signs and symptoms, compartmental pressure measurements can be secondary to trauma, post surgery, overuse, or exercise induced deep posterior compartment most common, can also occur in the anterior or lateral compartments (trauma) neural component and vascular component sympathetic involvement: -Vasomotor: abnormal skin color (purplish or mottled) -Pilomotor: loss of piloerection -Trophic: changes in skin texture -Sudomotor: loss of innervation to sweat glands

discuss the primary problem and primary course of treatment with ankle sprains

Some evidence suggests that the chief problem with function is loss of neuromuscular reflexes rather than involvement of passive restraints •That's the problem in developing chronic ankle sprains •Peroneal stretch reflex is inhibited with sprain, peroneal muscles lose protective response •Gastrocnemius is over active Strongest evidence for intervention is with proprioceptive and balance training

examination of a tibiofibular ligament sprain

Squeeze test •Painful = positive Rotation of the foot / ankle (transverse plane) •Painful = positive Girth measurement (swelling) Palpation Modified Squeeze/Rotation test •Manually stabilize the distal tib/fib joint •Dorsiflexion •Abduction / adduction (external / internal rotation of the ankle)

Supination-external rotation ankle fracture stages based on the Lauge-Hansen classification system

Stage 1: Rupture of anterior inferior tibiofibular ligament (high ankle sprain) Stage 2: Oblique fracture or spiral fracture of the lateral malleolus Stage 3: Rupture of post tibiofibular ligament or fracture of posterior malleolus of tibia Stage 4: Transverse (sometimes oblique) fracture of Tibial malleolus. (40% - 70% of all ankle fractures - most common mechanism!)

strengthening vs. balance/proprioception programs for lateral ankle sprain

Strengthening exercise had not been shown to impact long-term outcomes, may have short-term effect Training motor control (reflexes), balance, proprioception, and bracing have the best evidence

with examination for medial tibial stress syndrome, must rule out...

Stress fracture of the tibia Focal small area of the tibia, 3 cm max, not distal 2/3 of the tibia Myositis or fasciitis of posterior compartment (including infection) Posterior compartment syndrome Posterior tibial tendinosis/insufficiency, avulsion Nerve entrapment (saphenous or tibial) Ischemic disorder (popliteal artery)

why is gait important in preventing achilles tendonopathies?

Stress on the Achilles Tendon varies from 2000 N (450 lbs.) to 7000 N (1753 lbs.) in stance phase of gait Talar-calcaneal motion places uneven rotational force on the tendon •This is why it's important to have good foot mechanics Over-pronation (particularly late pronation when it should be resupinating) is an etiologic factor in noninsertional tendinitis

_____ locks the foot _____ unlocks the foot

Supination locks the foot Pronation unlocks the foot

common nerve pathologies of the ankle and foot

Sural nerve stretch Tarsal tunnel syndrome Interdigital nerve compression (Morton's neuroma) Plantar nerve entrapment

peroneus brevis tendinitis presentation

Symptoms: -Pain behind the lateral malleolus -Swelling and tenderness -Can mimic lateral ankle injuries Occurs after deconditioning and resuming activity -It is reported to be the strongest abductor of the foot

presentation of styloid avulsion fracture of the peroneus brevis tendon insertion

Tenderness, swelling, and pain on ambulation occur immediately Mechanism: sudden inversion of the foot with the muscle contracted Capsular attachment of the metatarsocuboid joint may be involved

the foot is more/less stiff when the arch is lower/higher

The foot becomes stiffer when the arch is higher The foot is less stiff when the arch is lower

what is the first ray of the foot? what does it articulate with?

The medial cuneiform and the 1st metatarsal Articulates with the navicular, 2nd or intermediate cuneiform, and the 2nd metatarsal

describe closed-chain subtalar supination

The talus abducts and dorsiflexes over the inverted calcaneus The first ray is plantar flexed The cuboid is compressed against the calcaneus and becomes extremely stable Serves as a fulcrum for the peroneus longus which plantar flexes and stabilizes the first ray at push-off

exam for achilles tendon rupture

Thompson-Doherty Squeeze Test Palpation of the medial head of the Gastrocnemius (rule out gastroc tear) Palpation of a gap in the tendon Royal London Hospital Test O'Brien's needle test (same as Thompson test except they stick needles in and look to see if needles move when you squeeze the calf) Strength test of gastroc

subtalar pronation can be excessive in...

Timing Amount of motion

Danis-Weber classification of ankle fractures

Type A: fracture below the ankle joint (anterior tib-fib joint) Type B: fracture at the level of the joint, with the tibiofibular ligaments usually intact Type C: fracture above the joint level which tears the syndesmotic ligaments

Freiberg's disease (what is it? treatment?)

Typically 2nd metatarsal area pain - when 2nd metatarsal grows too long Typically with female Occurs during a growth spurt Causes avascular necrosis of the metatarsal head Microfractures at the metaphysis and growth plate Typical treatment is surgery

what is a tarsal coalition? treatment?

Union of two or more tarsal bones Fibrous, cartilagenous, or osseous Most common cause of restricted joint motion Most often in Talonavicular, Talocalcaneal, or Calcanealcuboid See this a lot with late stage posterior tibialis syndrome and those with neurological problems Treatment: surgery - fuse foot in a good position

explain the common mechanism of an achilles tear

Usually, overuse leads to tendinosis, which then eventually causes a tear

gait cycle

Weight Acceptance - Initial contact/loading response: -Rearfoot: •Tibial internal rotation •Talocrural plantar flexion •Subtalar joint pronation - Talar adduction and plantar flexion; Calcaneal eversion -Midfoot: •Midtarsal pronation •Unlocking of cuboid / navicular •Forward displacement of talus -Forefoot: •dorsiflexion of first ray Midstance: -Rearfoot: •Early: Anterior movement of tibia over the talus, reversal of subtalar pronation (supination movement, not position) •Midstance: Ankle dorsiflexion, subtalar neutral •Late: Continued anterior movement of tibia on talus, subtalar supination, abduction and dorsiflexion of the talus -Midtarsal: reversal of pronation -Forefoot: full weight bearing on the metatarsal heads Push-off and Propulsion (terminal stance and preswing): -Rearfoot: •Talocrural: tibial external rotation, talus is abducted, dorsiflexed •Subtalar: supination -Midfoot: •Midtarsal supination - cuboid and navicular are rigid, navicular is raised with dorsiflexion of talus -Forefoot: •First ray plantar flexion, first MTP dorsiflexion Resupination: Pre-swing - great toe extension --> Windlass - tightens plantar aponeurosis --> Stable midtarsal joint --> Locked cuboid --> Cuboid is now pulley for peroneous longus --> Stabilizes first ray in plantar flexion --> Pre-swing - great toe extension

treatment of ankle instability when acute vs long term

When acute: -Address pain and swelling - RICE Long term -proprioceptive deficits -joint laxity -Balance deficits -Neuro-muscular inhibition

attachments of the deltoid ligament

a complex of multiple smaller ligaments attaching the distal tibia to the calcaneus, talus, and navicular

Lisfranc's joint injury often associated with...

a fracture of the metatarsal bases

chronic ankle instability is associated with... (as it pertains to the radius of the talus and coverage of the talus)

a larger radius of the talus and less coverage of the talus by the distal tibia

interpretation of odds ratio

a measure of the effect size odds ratio greater than 1 = the event is more likely to occur based on the variable of interest odds ratio = 1 implies the event has an equal chance of happening or not happening (50/50 odds) odds ratio less than one indicates the event is less likely

medial tibial stress syndrome (what is it? how does it develop?)

a specific category of shin splints involves muscle, periosteal tissue, bone reaction periosteal remodeling in response to stress; inflammation of the periosteum due to traction loading from muscle attachment at the medial border of the tibia

externally rotating the foot is described as what motion?

abduction

risk factors for acute lateral ankle sprain according to the CPGs risk factors for ankle instability according to the CPGs

acute lateral ankle sprain: (1) have a history of a previous ankle sprain (2) do not use an external support (3) do not properly warm up with static stretching and dynamic movement before activity (4) do not have normal ankle dorsiflexion range of motion (5) do not participate in a balance/ proprioceptive prevention program when there is a history of a previous injury ankle instability: (1) have an increased talar curvature (2) are not using an external support (3) did not perform balance or proprioception exercises following an acute lateral ankle sprain

CPGs for diagnosis of acute lateral ankle sprains CPGs for diagnosis of ankle instability

acute lateral ankle sprains: -clinicians should use the clinical findings of level of function, ligamentous laxity, hemorrhaging, point tenderness, total ankle motion, swelling, and pain to classify a patient with acute ankle ligament sprain into the ICD category of sprain and strain of ankle and the associated ICF impairment-based category of ankle stability and movement coordination impairments ankle instability: -clinicians may incorporate a discriminative instrument, such as the Cumberland Ankle Instability Tool, to assist in identifying the presence and severity of ankle instability associated with the ICD category of disorder of ligament, instability secondary to old ligament injury, ankle and foot, and the associated ICF impairment-based category of ankle stability and movement coordination impairments

mechanism of injury for posterior tibialis tendon insufficiency

acute rupture can occur traumatically, or a rupture of a chronic degenerative tendon

internally rotating the foot is described as what motion?

adduction

surgical repair for ankle instability and their effectiveness

anatomical repair - anatomic repair of the anterior talofibular and calcaneofibular ligaments is recommended when the quality of the ruptured ligaments permits augmentation (tenodesis) - nonanatomic tenodesis reconstructions have poor long-term results, sacrifice peroneal tendons, and disrupt normal ankle and hindfoot biomechanic anatomic reconstruction - anatomic reconstruction with autograft or allograft should be performed when ligaments are attenuated

with an anterior drawer test of the ankle, if the foot deviated medially, indicative of...

anterior talofibular ligament sprain

in high ankle sprains, what ligament is sprained? what else can be involved?

anterior tibiofibular ligament sprained can also be involved: -Posterior tib-fib ligament -Interosseous membrane (can cause mortise to widen) -Deltoid ligament

phonophoresis

anti-inflammatory cream put on the skin, use ultrasound to get the medicine into the tissues

iontophoresis

anti-inflammatory ion cream put on the skin, use electric current with assumption that like forces repel, to push the medicine into the tissues

treatment for bony impingement syndromes

anti-inflammatory medication taping for stability improve joint mechanics

motion is defined by the...

axis of rotation

BESS manual is used for...

balance testing

CPGs for differential diagnoses of acute lateral ankle sprains CPGs for differential diagnoses of ankle instability

basically for both, you should check for other issues that are inconsistent with suspected diagnosis, including the Ottawa ankle and/or foot rules

bimalleolar vs. trimalleolar ankle fractures

bimalleolar: fracture through both malleoli trimalleolar: lateral malleolus, medial malleolus, and the distal posterior aspect of the tibia •unstable injury, surgical intervention (open reduction, internal fixation) indicated

true or false? with overpronation, arches will be fallen

both true and false often yes, but arch does not have to be gone for overpronation to occur

Sever's disease (what is it? treatment?)

calcaneal apophysitis Heel pain in children (typically 16 or younger) Pain with activity Inflammation of the epiphyseal plate Treatment: -Heel cup may help -Heel lift -Taping, bracing -Usually improves in 4 to 6 weeks

dorsiflexion limitations > plantar flexion limitations > adduction limitations > rotation limitations indicative of...

capsular pattern of midtarsal joints

inversion limitations > eversion limitations indicative of...

capsular pattern of the subtalar joint

plantar flexion limitations > dorsiflexion limitations indicates...

capsular pattern of the talocrural joint

most of the evidence on dry needling is what type?

case series (level IV - not super high level of evidence)

40% of lateral ankle sprain patients develop....

chronic ankle instability

CPGs for diathermy post ankle sprain

clinicians can utilize pulsating shortwave diathermy for reducing edema and gait deviations associated with acute ankle sprains. (weak evidence)

CPGs for ultrasound post ankle sprain

clinicians should not use ultrasound for the management of acute ankle sprains

CPGs for cryotherapy post ankle sprain

clinicians should use repeated intermittent applications of ice to reduce pain, decrease the need for pain medication, and improve WB following an acute ankle sprain (strong evidence)

Talipes Equinovarus - what is it? causes? treatment?

clubfoot •Rear foot varus, inversion of the heel •Metatarsus adductus •Rear foot equinus (PF) •Rigid once child matures with deformity may be genetic •May be flexible or rigid, depends on stage/age/etiology •If its flexible, they'll put it in a brace •If it's rigid, surgery

if patient has less than 10 degrees dorsiflexion, you will see...

compensation in some way in their gait

effectiveness of saline and lidocaine injections vs plate-rich plasma injections for achilles tendinopathy

conflicting evidence differences in effectiveness may be due to volume rather than the injectate

Treatment of entrapment of interdigital nerves

consider orthotics steroid injection surgery to excise neuroma (in most cases the neuroma comes back - so if we get them back after surgery we can improve mechanics and try to prevent it from coming back)

theory behind rearfoot posting

control calcaneal eversion and tibial IR after heel strike

the correlation between function and clinical open chain measurements of the subtalar joint

correlation not understood

chronic tendon issues are (inflammatory/degenerative)

degenerative

majority of achilles tendon issues are (inflammatory/degenerative) which means...

degenerative so doing things for inflammation may actually inhibit recovery - we actually might want to stimulate inflammation in order to promote remodeling

eversion ankle sprains affect which ligament?

deltoid ligament (especially the middle portion)

manual therapy to improve dorsiflexion

distraction posterior glide of talus

limited ___ predisposes individual to lateral ankle sprains

dorsiflexion (just strengthening the muscles around the ankle is insufficient to prevent or treat ankle sprains, balance and proprioception are also key elements in treatment and prevention)

primary mechanism of injury for a high ankle sprain/syndesmosis injuries

dorsiflexion and rotation

capsular pattern of the midtarsal joints

dorsiflexion limitations > plantar flexion limitations > adduction limitations > rotation limitations

surgical options for posterior tibial tendon insufficiency (when are each applicable?)

effective when foot is still mobile: -tenosynovectomy (drain tendon sheath) -Tendon Transfer: change tendons of FDL or FHL to compensate for tibialis posterior when foot is stiff: -arthrodesis •Talonavicular - fuse talus to navicular •Double Arthodesis: talonavicular and calcaneocuboid - fuse talus to navivular and calcaneus to cuboid •Triple Arthrodesis: correct hindfoot valgus (by cutting wedge out of calcaneus) and Achilles tendon lengthening

treatment of styloid avulsion fracture of the peroneus brevis tendon insertion

elastic wrap and crutches, cast, or cast boot a surgical repair may be performed

presentation of tarsal tunnel syndrome

entrapment of: •posterior tibial nerve behind the medial malleolus •lateral and medial plantar nerves (tibial nerve divides into these nerves) enter tunnels within the abductor hallucis muscle •calcaneal nerve may pierce the laciniate ligament High Tarsal Tunnel Syndrome •proximal posterior tibial nerve in distal 1/3 of the leg Traditional Tarsal Tunnel Syndrome: •entrapment of the posterior tibial nerve occurs behind the medial malleolus (If tendon sheath gets inflamed or if hyperpronation occurs) •a hypermobile (excessive pronation) subtalar joint may be involved Distal Tarsal Tunnel Syndrome: •first branch of lateral plantar nerve compressed at the superior abductor hallucis muscle •lateral plantar nerve compressed at the inferior abductor hallucis where it joins the plantar fascia •associated with excessive pronation

presentation of deep peroneal nerve entrapment

entrapped under the inferior extensor retinaculum, as the nerve passes under the extensor hallucis brevis, or by osteophytes from the talonavicular joint poor fitting shoes, activity nerve symptoms of anterior leg

effectiveness of needling in achilles tendinopathy

evidence for lots of benefit irritates the tissue to stimulate remodeling most evidence is case series (level IV - not super high level of evidence) improves patient-reported outcome measures in patients with tendinopathy dry needling and hydrostatic decompression for non-insertional tendinopathy •At 12 and 24 months, >75% of patients where satisfied with treatment, >85 returned to sporting interests (There is a trend that shows that the addition of autologous blood products may further improve these outcomes)

abnormal supination (what is it? causes?)

failure of the rear foot or midfoot to adequately unlock to allow shock absorption intrinsic causes: -forefoot valgus -rigid plantar flexed first ray -uncompensated rear foot varus or foot deformity -spastic inverter muscles extrinsic causes: -compensation for tibial valgum, genu valgum, hip dysfunction

true or false? for the BESS assessment, the patient keeps their shoes on

false

true or false? there is a clear consensus on a gold standard for therapy for plantar fasciitis

false

true or false? subtalar neutral is represented by the calcaneus aligned parallel to the tibia

false Neutral IS NOT ALWAYS represented by the calcaneus aligned parallel to the tibia Neutral may be an inverted position of the calcaneus compared to the long axis of the tibia (described as calcaneus varus or rearfoot varus)

true or false? What happens at the forefoot controls what's going on at the rest of the foot

false What happens at the rearfoot controls what's going on at the rest of the foot

true or false? a drawer test should be performed on an acute ankle sprain

false a drawer test to acute injury will not be informative bc of swelling and muscle spasticity - wait a few days to do this

true or false? for the tandem stance section of the BESS assessment, patient stands with non-dominant leg in front of dominant

false dominant leg in front of non-dominant

true or false? for the BESS assessment, the patient stands with hands at their side

false hands on hips

true or false? the achilles tendon has a synovial sheath

false no synovial sheath - the tendon is surrounded by paratendon (site of paratendinitis in non-insertional tendinosis).

true or false? for the single leg stance section of the BESS assessment, patient stands on their dominant leg

false non-dominant

true or false? the axes for the ankle and foot are parallel to the cardinal planes

false the axes for the ankle and foot are not perpendicular nor parallel to the cardinal planes

true or false? the axes for the ankle and foot are perpendicular to the cardinal planes

false the axes for the ankle and foot are not perpendicular nor parallel to the cardinal planes

true or false? there is a relationship between restoration of ROM and improve functional outcome in chronic ankle instability

false there is not relationship between restoration of ROM and improve functional outcome in chronic ankle instability

higher prevalence of medial tibial stress syndrome in...

females people with higher BMI history of low activity previous LE injury incidence is reported as 11% to 35% of runners, aerobic dancers, and military personnel

how to calculate subtalar neutral

find full subtalar ROM divide by 3 neutral is 1/3 from full eversion

if you dorsiflex great toe, what happens at the first ray?

first ray will plantar flex

pes planis - what is it? causes?

flat foot deformity causes: -tibialis posterior dysfunction -tarsal coalition -rearfoot valgus -cavus foot, plantar flexed calcaneus/talus

Talipes Calcaneovalgus - what is it? causes? treatment?

flexible flat foot deformity lots of dorsiflexion due to malposition of fetus in uterus (feet remain dorsiflexed and everted), lower quarter externally rotated calcaneus is everted and the talus is plantar flexed treated with casting

motions at the MTP joints

flexion and extension

capsular pattern of the interphalangeal joints

flexion limitations > extension limitations

forefoot varus vs. forefoot valgus (what is it? presentation?)

forefoot varus: -looking down at heel with patient in prone, medial side of forefoot is farther foreward -inversion deformity of the forefoot with reference to the bisection of the calcaneus -2 methods of compensation: 1st ray plantar flexion or pronation at the rear foot (most common compensation - can be in amount, time or both and can be in rear foot or in leg) forefoot valgus: -looking down at heel with patient in prone, lateral side of forefoot is farther forward -eversion deformity of the forefoot with reference to the bisection of the calcaneus -2 methods of compensation: invert the calcaneus or supinate the foot

discuss isokinetic exercise for ankle instability

functional test scores in the injured ankles as compared to the opposite healthy ankles displayed a significant improvement did not demonstrate as much chronic instability than people who did not do this training

at what level of strain will a ligament start to weaken?

greater than 3%

hallux limitus vs. hallux rigidus

hallux limitus - limited ROM hallux rigidus - ROM pretty much gone 1st ray needs to plantar flex 20 degrees to allow the MTP joint to extend (dorsiflex) the full 60 degrees need for optimal foot function -In hallux limitus, 1st ray is not plantar flexing, which means great toe can't extend -In hallux rigidus, problem is at the joint - the joint of the great toe is eroding

most common sprain in football

high ankle sprain (anterior tibiofibular ligament)

____ ankle sprains take the longest to heal

high ankle sprains

vascularity and innervation of the paratendon around the achilles tendon

highly vascularized and innervated

Type of achilles tendon rupture repair depends on...

how much viable tendon is left

rules for manipulation as treatment for ankle instability

if 3 or 4 variable are present, ankle manipulation may be beneficial -symptoms worse when standing -symptoms worse in evening -navicular drop >5.0mm -distal tibiofibular joint hypomobility

Ankle capsular tear can lead to ____ as scarring occurs

impingement (capsule flips back in between talus and distal tibia and gets pinched between)

when is surgery indicated for lateral ankle sprains?

in individuals' with chronic instability and recurrent acute lateral ankle sprains

tears of the peroneus brevis tendon occur where?

in the fibular groove posterior to the lateral malleolus can have longitudinal fissures

important factors in management of lateral ankle sprains

increasing dorsiflexion ROM strengthening muscles around ankle (however, only this is insufficient) arthrokinematic motion of the talus (talus needs to be sitting back in the mortise) balance and proprioception are key elements in treatment and prevention

effectiveness of saline and lidocaine injections for achilles tendinopathy

injection of high volume saline and lidocaine reduces pain and improves function

common bony impingement syndromes

interphalangeal joint of the hallux metatarsophalangeal joint of the hallux (Hallux rigidus) metatarsophalangeal joints (Freiberg's disease) medial midfoot impingements subluxation of the cuboid spurs of the ankle joint (distal tibia, talar neck, multiple spurs)

intrinsic vs extrinsic etiology of abnormal foot mechanics

intrinsic: dysfunction within the foot extrinsic: dysfunction outside of the foot

it is important to palpate the peroneal tendons with a _____ because ____

inversion ankle sprain check for their involvement (make sure they're not tender and that they're sitting behind malleolus, not on top of)

isolated anterior talofibular tear very common with...

inversion ankle sprain (66%)

capsular pattern of the subtalar joint

inversion limitations > eversion limitations

most inversion ankle sprains are a ____ tear

isolated anterior talofibular (66%)

Lisfranc's joint

joint between metatarsals and tarsals

subtalar joint consists of...

joint between talus and calcaneus

what type of ankle brace provides the greatest stability?

lace-up brace

ankle joint equinus (what is it? causes? presentation?)

lack of dorsiflexion of the ankle with the subtalar joint in neutral position can be seen with spasticity with neurological problems common cause: limited flexibility of the gastrocnemius and soleus other causes: •prolonged cast immobilization in PF or crutch use, habitual use of high heeled shoes •Congenital gastroc-soleus tightness (from birth) •Calf muscle spasms (due to CP) •Bony block post-fx •Displaced talus with anterior impingement compensatory movements/positions: •Pronate the foot excessively •Toe walk •Early heel rise during terminal stance

most common ankle sprain

lateral ankle sprains

management of compartment syndrome

managed conservatively or surgically depending on degree of vascular involvement and cause surgery = fasciotomy - they will cut compartment and drain compartment, then suture the skin (but usually wait a few days to suture bc it will likely burst) conservative management: •Ice, elevation, (padding, compression depending on stage) •Correct proximal and distal mechanics •Stretching and range of motion •Graduated exercise, no symptom reproduction •May be months to a year before return to activity •Repeated episodes = surgical intervention

treatment for cuboid subluxation

manipulation evaluate for stability

CPGs for interventions for plantar fasciitis

manual therapy (A): -joint mobilizations -soft tissue mobilizations -procedures to treat relevant lower extremity joint mobility and calf flexibility deficits stretching (A): -plantar fascia-specific and gastrocnemius/soleus stretching to provide short-term pain relief -heel pads may be used to increase benefits of stretching taping (A): -antipronation taping for immediate pain reduction and improved function -may use elastic therapeutic tape applied to the gastrocnemius and plantar fascia for short-term pain reduction foot orthoses (A): -use foot orthoses, either prefabricated or custom fabricated/fitted, to support the medial longitudinal arch and cushion the heel to reduce pain and improve function for short-to longterm periods, especially in those individuals who respond positively to antipronation taping techniques night splints (A): -should prescribe a 1- to 3-month program of night splints for individuals with heel pain/plantar fasciitis who consistently have pain with the first step in the morning physical agents: -electrotherapy (D): manual therapy, stretching and foot orthoses much more useful than electrotherapeutic modalities -low-level laser (C): to reduce pain and activity limitations -phonophoresis (C): to reduce pain -ultrasound (C): cannot be recommended footwear (C): -to reduce pain, clinicians may prescribe (1) a rocker-bottom shoe construction in conjunction with a foot orthosis, and (2) shoe rotation during the work week for those who stand for long periods education and counseling for weight loss (E) therapeutic exercise and neuromuscular re-education (F): -for muscles that control pronation and attenuate forces during weight-bearing activities dry needling (F): -cannot be recommended

discuss chronic instability of the ankle

many people experience chronic instability of the ankle following an ankle sprain After 1 year of follow-up, 5-33% of patients still experienced pain and subjective instability Within a period of 3 years, as much as 34% of the patients reported at least 1 re-sprain From 36% up to 85% of the patients reported full recovery within a period of 3 years (after 3 years, probability of re-sprain becomes lower)

____ posts can exacerbate medial plantar nerve entrapment

medial forefoot posts

common trigger point with plantar fascia pain, heel pain and achilles pain

medial gastroc

Chopart's joint

midtarsal joint

CPGs for electrotherapy post ankle sprain

moderate evidence both for and against the use of electrotherapy for the management of acute ankle sprains

CPGs for laser therapy post ankle sprain

moderate evidence both for and against the use of low-level laser therapy for the management of acute ankle sprains

causes of forefoot valgus

most common: rigid, plantar flexed first ray •The head of the first metatarsal is out of plane with the other metatarsal heads •The first ray lacks dorsiflexion ROM •See a high arched (Cavus) foot

axes of the ankle and foot

motion is triplanar the axes for the ankle and foot are not perpendicular nor parallel to the cardinal planes motion occurs simultaneously in all three planes to some degree the predominant plane in which motion occurs is dependent upon the orientation of the axis

presentation of Medial Plantar Nerve Entrapment

occurs as the nerve passes near the master knot of Henry associated with excessive forefoot abduction or hallux rigidus pain radiates distally to the toes and proximally to the ankle tender under the navicular tuberosity pain reproduced with everting the heel or heel raises sensory changes after activity

evaluation for orthotics includes...

open chain evaluation: •Observation - any abnormalities? •Subtalar joint range of motion - determine STJ neutral •Rearfoot / forefoot relationship •Clear the hips •Knee examination as appropriate closed chain/standing evaluation: •Observation •Navicular / talar position •Tibial / Calcaneal angle measurement •STJ range of motion (calcaneal inv / ev) •First ray position •First MTP joint dorsiflexion •Windlass •Pelvis and LE landmarks, LE functional length with STJ in neutral and relaxed standing •Trendelenburg •Functional testing dynamic evaluation: gait •Initial contact to Loading response (rearfoot moves toward pronation) •Midstance (early - rearfoot begins to resupinate) •Late stance to preswing (supinated) -Rearfoot -Midfoot -First ray plantar flexed -MTP extended -Lower extremity and trunk rotating

open and closed packed positions of the MTP joints

open-packed: 10 degrees extension closed-packed: full extension

open and closed packed positions of the subtalar joint

open-packed: midway between inversion and eversion with 10 degrees plantarflexion closed-packed: full inversion

open and closed packed positions of the midtarsal joints

open-packed: midway between supination and pronation, 10 degrees of plantarflexion closed-packed: full supination

open-packed and closed-packed positions of the interphalangeal joints

open-packed: slight flexion close-packed: full extension

treatment of medial plantar nerve entrapment

orthotic controlling pronation but no direct pressure on the nerve heel lift surgery

presentation of sinus tarsi syndrome

pain increases with WB activities exacerbated with impact activities exacerbated by pronation can be the sequel to a sprained ankle tender deep in the sinus tarsi abduction and eversion of the heel reproduces pain

tendinitis vs. paratendinitis vs. tendinosis

paratendinitis: paratenon (covering that wraps around tendon) is inflamed tendinitis: tendon itself is inflamed tendinosis: degenerative, chronic

the achilles tendon is surrounded by...

paratendon (NOT a synovial sheath)

if inflammation is involved in an achilles tendon injury, it is usually ____ that is involved

paratenon (leading to paratendinitis)

with inversion ankle sprains, it is important to palpate____ to check for its involvement

peroneal tendons

a large number of the collagen fibers in the achilles tendon are continuous with the...

plantar fascia

plantar flexion at the first ray also... dorsiflexion at the first ray also...

plantar flexes and everts dorsiflexes and inverts

plantar flexion at the fifth ray also... dorsiflexion at the fifth ray also...

plantar flexes and inverts dorsiflexes and everts

capsular pattern of the talocrural joint

plantar flexion limitations > dorsiflexion limitations (Proportionally, bc ROM is different for each)

Most common foot problem for referral to physical therapy

plantar heel pain (most likely under-reported as many do not seek medical attention)

____ drives the motion of the midtarsal joint describe how

position of the subtalar joint and ground reaction forces Subtalar Pronation: •During subtalar joint pronation, the talus plantar flexes and adducts •This motion of the talus lowers the navicular •The change in navicular position changes the orientation of the midfoot axes of motion Subtalar Supination: •During subtalar supination, the talus dorsiflexes and abducts •This movement (change in position) raises the navicular and alters the axes for the midtarsal joint During subtalar supination, the axes of the midtarsal joint become more perpendicular - The foot becomes stiffer, the arch higher During subtalar pronation, the axes of the midtarsal joint become more parallel - The foot is less stiff, the arch lower

If you feel bone in the plantar surface of child's foot, what do you suspect? what do you do?

possibly congenital vertical talus - refer out for imaging!!

associated syndesmosis injury with high ankle sprain results in...

prolonged morbidity and higher incidence of residual symptoms

if someone has a tibial varum, they will compensate in the foot by...

pronating

prevalence of high ankle sprains/syndesmosis injuries

rare except for contact sports and sports that immobilize the foot (e.g. alpine skiing)

What happens at the ____ controls what's going on at the rest of the foot

rearfoot

regions of the foot

rearfoot midfoot (midtarsal or transtarsal joint) forefoot (Lisfranc's joint - tarsometatarsal joint)

standing in rearfoot valgus - what is the likely intrinsic deformity?

rearfoot valgus is typically a compensation for structural subtalar varus

effectiveness of external ankle supports in prevention of inversion ankle sprains

reduction of ankle sprain by 69% with the use of ankle brace and by 71% with the use of ankle tape among previously injured athletes no type of ankle support was found to be superior than the other

treatment for suspected Lisfranc's injury

referral, imaging required if confirmed: •If displaced bone, instability, fracture, treatment will involve surgical correction - open reduction, internal fixation

If pt is tender anterior to the achilles tendon, what is likely the issue?

retrocalcaneal bursa may be inflamed

metatarsus adductus

rigid deformity adduction of forefoot

Pes cavovarus

rigid deformity pes cavus (plantar flexion of first ray, high arch) + calcaneal varus, plantar flexion of first ray

pes cavus

rigid deformity plantar flexion of forefoot - very high arch

Windlass test shows us...

rules in a diagnosis of plantar fasciitis high specificity, lower sensitivity (if they get a positive, they have plantar fasciitis, if they have plantar fasciitis it's not guaranteed that they will for sure get a positive)

Lisfranc's injury

severe midfoot/forefoot sprains can have dislocation and/or fracture referral, imaging required if displaced bone, instability, fracture, treatment will involve surgical correction open reduction, internal fixation

predisposing factors to achilles tendinopathy

shoes tibia vara (bow-legged) tight hamstrings rear foot and forefoot deformity

causes of forefoot varus

soft tissue imbalance -we as PTs can change this over time deformity of talus -in utero, position of foot causes talus to form abnormally

with an anterior drawer test of the ankle, if the foot deviated laterally, indicative of...

sprain of the anterior portion of the deltoid ligament

what things will we need to wait to assess until ankle sprain is no longer acute to examine?

stability testing (drawer tests, etc.) will be too swollen to be accurate for first 4-5 days

forefoot function depends on...

stable metatarsals and mobile metatarsalphalangeal and intermetatarsal joints

treatment of posterior tibial tendon insufficiency at different stages

stage 1: -tenosynovectomy (drain tendon sheath) -NSAIDs (may not be a good idea though for bone healing and soft tissue healing) -Orthotic, avoid aggravating footwear -Cut activities that are provocative (WB, high impact) -Alternative training for strength and endurance -Eccentric and concentric exercise for posterior tibialis stage 2: -NSAIDs -extensive shoe insert (orthotic) -UCBL orthosis (support foot in non-abducted position, extensive arch support) -Ankle brace to control eversion -Surgery stage 3: -realignment of the hindfoot and arthrodesis

chronic use of ____ can lead to rupture of the achilles tendon

steroid

pathway and functions of posterior tibialis

stretched from behind the medial malleolus along the arch of the foot under the navicular and to all the tarsals supports the arch and keeps foot from abducting

tailor's bunion - what is it?

subluxation of proximal phalanx from the head of the 5th metatarsal in transverse plane -often a bone spur on 5th metatarsal head

if someone has a tibial valgum, they will compensate in the foot by...

supinating

most common mechanism of ankle fracture

supination-external rotation (which is a Weber B) Stage 1: Rupture of anterior inferior tibiofibular ligament (high ankle sprain) Stage 2: Oblique fracture or spiral fracture of the lateral malleolus Stage 3: Rupture of post tibiofibular ligament or fracture of posterior malleolus of tibia Stage 4: Transverse (sometimes oblique) fracture of Tibial malleolus

treatment for trigger points

sustained pressure dry needling laser brief cool and stretch

presentation of medial tibial stress syndrome

symptoms can be bilateral, located on the distal 2/3 of the tibia (posterior/medial) history: -pain induced by WB exercise -pain at posterior medial border of tibia, no paresthesia (no neurological or vascular signs or symptoms) -focal pain on bone: suspect stress fracture (2 cm to 3 cm area) -MTSS has diffuse area for pain (>5 cm) Palpation of the posterior medial border of the tibia produces diffuse discomfort, bone surface feels uneven (bumpy or grainy) Pain typically during exercise and better with rest unless severe problem

how long does it take an ankle sprain to heal?

takes 6 weeks to start healing; takes about 6 months to a year for collagen to fully heal

axis of the talocrural joint axis of the subtalar joint axis of the midtarsal joint

talocrural: bottom tip of tibia to bottom tip of fibula - fibula is lower so it is slightly tilted lower on the lateral side subtalar: coming from posterolateral to anteromedial midtarsal joint: 2 axes! -longitudinal: top medial to bottom lateral, almost longitudinal (inversion and eversion) -oblique (transverse): top medial to bottom lateral, but more transverse (dorsiflexion/abduction and plantar flexion/adduction)

midtarsal joint consists of...

talonavicular joint: talus and navicular (modified ball and socket) calcaneocuboid joint: calcaneus with cuboid (saddle joint) -The bifurcated, calcaneocuboid (short plantar), and long plantar ligaments support the joint -Gliding movement with conjunct rotation cubonavicular joint: navicular with cuboid (fibrous joint) -slight gliding movement talocalcaneonavicular (TCN) joint

Most common cause of restricted joint motion in the tarsals

tarsal coalitions

Cuboid dysfunction indicated by...

tenderness on cuboid and prominence of cuboid

types of peroneus longus tendon injuries

tendinitis acute rupture chronic tears (longitudinal)

treatment for achilles tendinopathy

tendinitis: •Rest, ice, and NSAIDs. •Heel lift (limited evidence) / orthotic •Correct functional / structural deformities •Modalities •Eccentric exercise (not while it's acute!!) tendonosis: •Eccentric exercise, resistance exercise, overloading (mixed results with over-loading exercises; latest literature supports that it does not matter if it is eccentric or concentric, as long as we are progressively loading - we want to irritate the tendon to get the inflammatory response and producing stress on tendon) •Rest •Best if they don't take NSAIDs bc it's chronic •Laser - mixed literature •Needling •Soft tissue mobilization (can be with instruments) •Orthotics •Extracorporal shock wave therapy (limited evidence) •Blood product injections (not amazing) •Regenerative therapy (sugar water, phenol, isotonic water, growth hormone, testosterone) - stimulates tissue growth (we can't do this but physicians can and then patient comes for PT)

the role of vasculature in achilles tendinopathy

tendon avascular just proximal to the insertion on the calcaneus plays a role in insertional tendinopathy

explain the twisting fibers of the achilles tendon and why they are important

the distal tendon twists with the more posterior fibers becoming lateral at the distal end part of the reason that you develop more tension in the tendon with pronation - thought to lead to some of the problems with achilles tendinopathy

when would you feel nodules with achilles tendinopathy? why do you feel them?

the nodules are cysts in the tendon noninsertional tendinitis •Peritendinitis with tendinosis •Tendinosis

if motion is restricted in one plane of the ankle and foot, what happens to motion at the other planes

the other planes will in some way be influenced

stability of the ankle is dependent upon...

the position of the ankle the further from neutral dorsiflexion, inversion, eversion, the more the ankle is dependent upon neuromuscular and ligamentous support almost always, pt was plantar flexed when sprain occurred "If one has to depend on the ligaments to support the ankle, they will injure the ankle"

true or false? What happens at the rearfoot controls what's going on at the rest of the foot

true

true or false? a large number of the collagen fibers in the achilles tendon are continuous with the plantar fascia

true

true or false? for the BESS assessment, the patient stands with hands on their hips

true

true or false? for the single leg stance section of the BESS assessment, patient stands on their non-dominant leg

true

true or false? for the tandem stance section of the BESS assessment, patient stands with dominant leg in front of non-dominant

true

true or false? the correlation between function and clinical open chain measurements of the subtalar joint is not understood

true

true or false? subtalar neutral may be an inverted position of the calcaneus compared to the long axis of the tibia

true Neutral IS NOT ALWAYS represented by the calcaneus aligned parallel to the tibia

shoe stiffener (what is it? what is it used for?)

used for midfoot sprains stiffens the foot so that person is not putting as much forces on the midfoot as they normally would while walking

process of shockwave therapy in achilles tendonosis

waves go into tendon - irritates it and promotes inflammatory process to stimulate remodeling

subtalar valgus deformity (what is it? presentation?)

when pt is in subtalar neutral, they demonstrate eversion of the calcaneus not very common compensate by internally rotating leg (patella will not be facing forward)

subtalar varus deformity (what is it? presentation?)

when pt is in subtalar neutral, they demonstrate inversion of the calcaneus typically compensate by everting (pronating) to bring the foot in contact with the floor •if they do not compensate, they take weight on the lateral foot (which can lead to injury) •over-pronate either in amount, in duration, or both

presentation of a lateral ankle sprain

while the ankle may demonstrate limited range of physiological motion, laxity may be present with joint play/accessory motions cannot control the ankle in certain situations and it "gives way"

Talar dome is wider (anteriorly/posteriorly), which means ______ of mortise with dorsiflexion

wider anteriorly widening of mortise with dorsiflexion

PT for posterior tibial tendon insufficiency post-surgery

work on DF ROM Medial heel wedge, forefoot correction or support with orthotic. Strengthening exercises WB: -Toe touch weight-bearing at 8 weeks -Full weight-bearing at 12 weeks Cast immobilization for 10 weeks Balance and proprioceptive training initiated early in PWB then progressed when patient is full WB (e.g., BAPs board)

PT for ankle fracture that is acute and treated with ORIF

•Cryocuff (the game ready!) or cold compression •Elevation and compression for swelling •Brace, boot •Begin WB in walking boot during the 2nd week following fracture, stationary bike, stirrup brace if no immobilization used •Bimalleolar fracture, may wear boot for 6 weeks

outcome measures for plantar fasciitis

•Foot Function Index (FFI) •Foot Health Status Questionnaire (FHSQ) •Foot and Ankle Ability Measure (FAAM) •Lower Extremity Functional Scale

presentation of plantar fasciitis

•Heel pain, plantar foot pain with first steps in the AM or after rest, improves somewhat then worsens at end of day •Pain with weight-bearing •Precipitated by activity, increased weight bearing •Dorsiflexion of the ankle is limited and typically painful

treatment for midfoot/forefoot sprains

•Ice, compression, elevation •Taping, bracing (extending across mid tarsal joint) •Manual therapy for dysfunctional cubiod, cuneiforms •Orthotic or stainless steel innersole •Balance, graded exercise

examination for midfoot/forefoot sprains

•Inversion / eversion of the midfoot on a stable ankle / rearfoot •Plantar flexion / dorsiflexion of the midfoot •Accessory motion testing •Palpation •Ottawa foot rule

presentation of midfoot/forefoot sprains

•Involvement of the midtarsal joint, possible subluxation of the cuboid •Cuboid dysfunction may be common complication to lateral ankle sprains, prevalence is not reported

predictive factors for plantar fasciitis

•Over pronation in some studies •Leg-length discrepancy indicated by CPGs: •Limited dorsiflexion at the ankle •High body mass •Running •Work related WB activities