chapter 13: lower leg, ankle, and foot ( magee p888)

Resting position of the TALOCRURAL (ANKLE) JOINT

10* of plantar flexion , midway between maximum inversion and maximum eversion. ** talocrural joint has one degree of freedom

Keen sign

Abnormal width of one ankle in relation. To the other

KEEN SIGN

abnormal width of 1 ankle in relation to the other may be caused by swelling, loss of integrity of the syndesmosis, or a malleolar fracture.

LATERAL LONGITUDINAL ARCH

calcaneus, cuboid,4th and 5th metatarsal make up lateral longitudinal arch. This arch is more stable and less adjustable than medial longitudinal arch. It is maintained by: peroneus longus, brevis, tertius, abductor digiti minimi, flexor digitorum brevis, plantar fascia, long plantar ligament.

CLAW TOES

claw toe deformity result in Hyperextension of metatarsophalangeal joint and flexion of the proximal and distal interphalengeal joints.

HAMMER TOE

extension contractures at the metatarsophalangeal joint & flexion contracture at proximal interphalengeal joint maybe flexed, straight or hyperextended.

MALLET TOE

flexion deformity of distal interphalengeal joint It can occur in any of the 4 lateral toes

FICK ANGLE OF THE FOOT

foot assumes a slight toe out position. The fick angle is approximately, 12* to 18* from the sagittal axis of the body. developing from 5* in children

With pes planus, eversion in the non-weight-bearing calcaneus

is greater than 10 degrees Dorsiflexion of the ankle may be limited with severe pes planus . Increased internal rotation may be present with femoral anteversion.

• Pes cavus

is the opposite foot configuration of pes planus. It presents as a high medial arch due to increased twisting or supination of the foot. The calcaneus is inverted. Tibialis anterior, tibialis posterior and the toe flexors are shortened.

TRANSVERSE ARCH

maintained by tibialis posterior, tibialis anterior, peroneus longus mm, plantar fascia. It consist of navicular, cuneiforms, cuboid, metatarsal bones.

closed packed-position of the TALOCRURAL (ANKLE) JOINT

maximum dorsiflexion

FOREFOOT VARUS

midtarsal deviation involves inversion of the forefoot on the hindfoot when subtalar joint is in neutral position. resembles ples planus bec it decrease the medial longitudinal arch.

capsular pattern of restriction of the TALOCRURAL (ANKLE) JOINT

more limited in plantar flexion than dorsiflexion ** joint is most Stable in Dorsiflexed position

METATARSUS ADDUCTUS ( HOOKED FOREFOOT)

most common foot deviation in children It may be seen at birth but often not noticed until child begins to stand. the foot appears adducted and supinated

HAGLUND DISEASE OR DEFORMITY

runner often build up bone and a callus on the heel, producing a pump bump as a result of pressure on the heel.

PLANTAR FLEXED FIRST RAY

structural deformity 1st ray big toe lies lower than the other 4 metatarsal bones so that the forefoot is everted when metatarsal bones are aligned.

FOREFOOT VALGUS

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

WEST POINTSPRAIN GRADING SYSTEM

used to determine the severity of the ankle sprains.

COMMON DEFORMITIES, DEBVIATIONS, & INJURIES OF THE FOOT

1. BUNIONETTE (TAILOR'S BUNION) 2. CLAW TOES 3. CLUBFOOT/TALIPES EQUINOVARUS 4. CROSSOVER TOE 5. CURLY TOE 6. EQUINUS DEFORMITY (TALIPES EQUINUS) 7. EXOSTOSIS (BONY SPUR) 8. FOREFOOT VALGUS 9. FOREFOOT VARUS 10. HALLUX RIGIDUS 11. HALLUX VALGUS 12. HAMMER TOE 13. HINDFOOT VALGUS (SUBTALAR OR REARFOOT VALGUS) 14. HINDFOOT VARUS (SUBTALAR OR REARFOOT VARUS) 15. MALLET TOE 16. METATARSAL ADDUCTUS (HOOKED FOREFOOT) 17. MORTON'S (ATAVISTIC OR GRECIAN) FOOT 18. MORTON'S METATARSALGIA (INTERDIGITAL NEUROMA) 19.PES CAVUS (HOLLOW FOOT OR RIGID FOOT) 20. PES PLANUS (FLAT FOOT OR MOBILE FOOT) 21. PLANTAR FLEXED FIRST RAY 22. POLYDACTYL 23. ROCKER-BOTTOM FOOT 24. SPLAY FOOT 25. TURF TOE

HINDFOOT /REARFOOT JOINT

1. Tibiofibular Joint 2. Talocrural (ankle) joint 3. Subtalar (talocalcanean) joint

5 Functions of the Foot

1. acts as support base that provides the necessary stability for upright posture with minimal muscle effort. 2. Provide mechanism for rotation of the tibia and fibula during the stance phase of gait. 3. Provides flexibility to adapt to uneven terrain. 4. Provide flexibility for absorption of shock. 5. acts as a lever during push-off

CLINICAL PREDICTION RULE FOR ANTEROLATERAL ANKLE IMPINGEMENT ** 5 of 6 symptoms must be positive (+)

1. anterolateral ankle joint tenderness 2. anterolateral ankle joint swelling 3. pain on forced dorsiflexion 4. pain on affected side with single leg squat 5. pain with activities 6. absence of ankle instability

3 sections in joint of the foot

1. hindfoot (rear foot) 2. midfoot 3. forefoot

PES PLANUS (FLAT FOOT OR MOBILE FOOT)

2 TYPES 1. rigid or congenital 2. acquired or flexible flat foot

Medial longitudinal arch -maintained by tibialis anterior Tibialis posterior Flexor diditorum longus, flexor hallucis longus, abductor halluces, flexor digitorum Bevis, plantar aponeurosis Plantar calacaneonavicular ligament.

Calcaneal tuberosity, talus, navicular, 3cuneiforms, 1st,2nd and 3rd metatarsal bone.

Fallen metatarsal arch

For non-weight bearing position, callosities are found over metatarsal heads

Genus recurvatum

Hyperextended knee

Exaggerated lateral tibia torsion

In stance with patella facing straight forward The feet pointed outward

peroneus longus, brevis and tertius. (Muscles that evert the foot )

In the pronated foot, these muscles are prone to developing trigger points and taut bands

J sign inverted

Inverted J sign Pathological patellar tracking or patellar instability Sudden movement medially to enter trochlea instead of normal smooth pattern.

Hallux valgus is a valgus orientation of the big toe or hallux, with an accompanying medial deviation of the first metatarsal bone.

It may be caused by, or contribute to, pes planus. The first metatarsophalangeal joint capsule becomes hypermobile; a callus and an inflamed, thickened bursa develop over the joint, which form a bunion. This is often due to poor footwear

Lateral meniscus

Large part small circle O shaped Excursion 10mm

Television or W position

Lead to excessive lateral tibia torsion

Transverse arch -consist of the navicular, cuneiform, Cuboid, metatarsal bone

Maintained by tibialis posterior Tibialis anterior Peroneus longus Plantar fascia

Locking in knee

Mean knee cannot fully extend with flexion normal. Loose bodies cause recurrent locking. Hamstring muscle spasm may also limit extension referred to as Spasm Locking

Pigeon toed deformity

Medial tibia torsion Feet point toward each other

Meniscus

Minimal innervation MinimL or no pain when damaged unless coronary ligament have been damaged as well

LATERAL longitudinal arch

More stable Less adjustable compared to medial longitudinal arch -maintained by Peroneus longs Proteus brevis Proteus tortious Abductor digit Minami Flexor digitorum bravos

Jumper's knee or sending -Larsen-Johansson syndrome

Pain after activity or with overuse characteristic of inflammatory condition Example SYNOVIAL pica irritation or early tendinosis or Para tenonitis

Medial tibia torsion

Position avoided to avoid medial torsion

Quadriceps Lag

Quad muscle are not strong enough to fully extend the knee

TALOCRURAL (ANKLE) JOINT

RESTING POSITION: 10* plantar flexion:, midway between inversion and eversion CLOSED PACKED:maximum dorsiflexion CAPSULAR PATTERN: plantar flexion, dorsiflexion

JOINTS OF THE MIDFOOT (MIDTARSAL JOINTS)

RESTING POSITION: midway between extremes of range of motion CLOSED PACKED POSITION: Supination CAPSULAR PATTERN: Dorsiflexion, plantar flexion, adduction, medial rotation

SUBTALAR

RESTING POSITION: midway between extremes of range of motion CLOSED PACKED: supination CAPSULAR PATTERN: limited range of motion (varus, valgus)

TIBIOFLIBULAR JOINT

RESTING: plantar flexion CLOSED PACKED: maximum dorsiflexion CAPSULAR PATTERN: pain when joint is stressed

Medial meniscus

Small part of large circle C shaped Excursion 2mm

Terrible triad of the knee **** Medial collateral ligament - posteromedial capsule -Medial meniscus -Anterior Cruciate

Valgus force involves 1. Medial collateral ligament - posteromedial capsule -Medial meniscus -Anterior Cruciate 2. Anterior Cruciate injuries 3. Posterior Cruciate LIGAMENTS 4.lateral collateral LIGAMENTS

EXOSTOSIS (BONY SPUR)

abnormal bony outgrowth extending from the surface of the bone. An increase in the bone mass at site of an irritative lesion in response to overuse, trauma or excessive pressure. it is common in dorsal 5th metatarsal bone or calcaneus, often called pump bump or runner's bump)

HELBING SIGN

achilles tendon appears to curve out ; may indicate fallen medial longitudinal arch , resulting in pes planus (flat foot) condition

Gastrocnemius and soleus

are primarily postural muscles and respond to stress by adaptively shortening

EQUINUS DEFORMITY (TALIPES EQUINUS)

deformity with limited dorsiflexion less than 10* at the talocrural joint. usually result of the contracture of the gastrocnemius or soleus or Achilles tendon. This contributes to plantar fasciitis, metatarsalgia, heel spurs and talonavicular pain.

HALLUX RIGIDUS

dorsiflexion or extension of big toe is limited because of OA of the 1st metatarsophalangeal joint

HINDFOOT VALGUS (SUBTALAR OR REARFOOT VALGUS)

eversion of the calcaneus when subtalar joint is in neutral position. The hindfoot is mobile, which may leave to excessive pronation and limited supination may result in genu valgum (knocked knee)

MORTON'S METATARSALGIA (INTERDIGITAL NEUROMA)

formation of digital neuroma in the interdigital nerve between 3rd and 4th toes. to confirm plantar palpation is better because dorsal plapation is more on stress fracture While walking or running mortion's metatarsalgia feel pain in outer border of forefoot. intermittent, cramp, shooting up the side to the tip.

A severe pes planus

has 10 to 15 degrees of hindfoot valgus

A mild pes planus

has four to six degrees of hindfoot valgus when measured in a standing posterior view

A moderate pes planus

has six to 10 degrees of hindfoot valgus

lateral longitudinal arch,

however, is a true architectural arch, with the cuboid bone forming the keystone between the calcaneus and the fourth and fifth metatarsals.

DELTOID OR MEDIAL COLLATERAL LIGAMENT

in the medial side of the joint. consists of the 4 separate ligaments 1. tibionavicular 2. tibiocalcanean 3. posterior tibiotalar ligaments superficially 4. anterior tibiotalar ligament

HINDFOOT VARUS (SUBTALAR OR REARFOOT VARUS)

inversiob of calcaneus when subtalar joint is in neutral position.

CURLY TOE

involves flexion deformity of both proximal and distal interphalengeal joints with the metatarsophalangeal joint in neutral or flexion, often combined with rotation. It is the result of contracture of the flexor digitorum brevis and longus tendon and most commonly seen in the 5th toe in children.

Morton's neuroma

is a swelling of the distal interdigital nerves of the foot, usually between the third and fourth metatarsals. It may be caused by hypermobility of the metatarsals. Pain results on compression or weight bearing, as the nerve is compressed between the bones. Morton's neuroma may be exacerbated by shoes that are too tight

PES CAVUS (HOLLOW FOOT OR RIGID FOOT)

may be congenital, neurological ex spina bifida, poliomyelitis, charcot-marie tooth disease.

HALLUX VALGUS

medial deviation of the head of 1st metatarsal bone in relation to the center of the foot. wearing tight pointed toes, tight stockings, high-heeled shoes.

Pronation of the foot

occurs primarily at the subtalar joint and secondarily at the midtarsal joint

SUPINATION

of the foot involves inversion and outward rotation of the heel, adduction of the forefoot with inward rotation at the tarsometatarsal joints to maintain contact with the ground and outward rotation at the midtarsal joints

CLUBFOOT /TALIPES EQUINOVARUS

on assessment ROM is limited and foot has abnormal form. Congenital deformity

BUNIONETTE (TAILOR'S BUNION)

prominent lateral 5th toe (metatarsal head). Often associated with pronated foot.

CHOPART JOINT

refers collectively to the midtarsal joints between the talus-calcaneus and the navicular-cuboid.

CROSSOVER TOE

result of weakening of the lateral collateral ligament of the metatarsophalangeal joint and insufficiency of the plantar plate along with the pull of extrinsic muscle resulting in medial deviation of the toe, most commonly in 2nd or 3rd toe. Often associated with hallux valgus.

ECCHYMOSIS

swelling or bruising

MORTON'S (ATAVISTIC OR GRECIAN) FOOT

the 2nd toe is longer than the 1st

Tibiofibular Joint

the inferior (distal) tibiofibular joint is a fibrous or syndesmosis type of joint. It is supported by anterior tibiofibular, posterior tibiofibular, and inferior transverse ligaments as well as the interroseous ligament. The movement of this joint are minimal but allow small amount of spread (1-2mm) at the ankle joint during dorsiflexion. Dorsiflexion at the ankle joint causes the fibula to move superiorly putting stress on both inferior tibiofibular joint at the ankle and superior tibiofibular joint at then knee. FIBULA -carries more axial load when it is dorsiflexed. On average fibula carries 17% of the axial loading. The joint is supplied by deep peroneal and tibial nerves.

Treatment Goals Treatment Plan With functional pes planus,

the therapist lengthens the shortened structures and the client strengthens the fatigued muscles.

With structural pes planus,

the therapist maintains tissue health and treats the compensatory structures.

The muscles supporting the arch in the dynamic foot — tibialis anterior and the peroneal muscles — are primarily phasic; that is, they respond to stress by fatiguing

tibialis anterior and the peroneal muscles — are primarily phasic; that is, they respond to stress by fatiguing

1. propulsion 2. support

two principal function of lower leg, ankle and foot For PROPULSION acts like flexible lever For SUPPORT they act like rigid structure that hold entire body.

TALOCRURAL (ANKLE) JOINT

uniaxial, modified hinge , synovial joint located between the TALUS, MEDIAL MALLEOLUS of the tibia, and LATERAL MALLEOLUS of the fibula. The talus is shaped so that in dorsiflexion it is wedged between the malleoli, allowing little or no inversion or eversion of the ankle joint. The talocrural joint is designed for stability, especially in dorsiflexion. In plantar flexion, it is much more mobile. This joint is responsible for dorsiflexion-plantar flexion movement that occurs in ankle foot complex.

A Morton's foot structure,

where the second metatarsal is longer than the first, allows the first metatarsal to become hypermobile. The body's weight is abnormally distributed through the head of the second metatarsal on the toe off phase of the gait cycle. This often results in callus formation and tenderness under the second metatarsal head. A Morton foot structure places stress on tibialis posterior and may occur with pes planus

shortened muscles, such as gastrocnemius, soleus and Achilles tendon,

which reduce the ability of the ankle to dorsiflex. This leads to compensation by the midtarsal joint

PES PLANU S Contraindications • Do not mobilize the hypermobile joints on the medial longitudinal arch.

• Do not passively stretch tibialis anterior and posterior, since this will allow increased pronation of the foot. • Avoid using heat on the plantar surface of the foot in the presence of an inflammatory process such as plantar fasciitis. • Friction techniques are contraindicated if the client is using anti-inflammatory medication