MSK INTERVENTIONS- ANKLE JOINT

APPLICATION QUESTIONS

1. A 60 year old patient injured his left lower limb in a motor vehicle accident 15 years ago,
as a result of which he developed left ankle arthritis. He underwent left ankle fusion
resulting in surgical fusion of the left talocrural joint (talus, fibula and tibia).
● What consequences would you expect? Would you expect change in motion of
forefoot in relation to the tibia, why or why not?
Limited Plantar flexion and dorsiflexion
Inversion and eversion, Adduction abduction might be limited

● Where might the corresponding increase or decrease in motion occur?

At the subtalar and forefoot. Subtalar joint and forefoot increase movement
because the dorsiflexion and plantarflexion is restricted at the rear foot.

2. 26-year-old runner complaints of frequent right ankle sprains with his foot in inversion.
He gives a history of initial sprains a year back which was left untreated.
● What soft tissues structures would be affected? How would they be affected?
Lateral collateral ligament and deltoid ligament
Anterior talofibular, posterior talofibular, calcaneofibular ligament (3,6,9 on
the clock)

● Why is an inversion sprain more common than an eversion sprain?

1. Deltoid ligament is on the medial side and it provides support.
2. Because of bony and ligamentous anatomy. Fibular malleoli extends further
down than the tibial malleoli.
3. Medial collateral ligament is stronger than the lateral one. Easier to tear
the smaller ligaments on the lateral side.

● What soft-tissue issues might contribute to abnormal foot positioning at the time
of contact in individuals with ankle sprains?
Inversion torque
Supinated and varus at the ankle
Weak pronators and delay activation of peroneus longus.
Delayed activation of the muscle- you have trained the muscle to be stronger
but not necessarily activate at the right time

3. A 44 year female complains of pain in his right foot when she runs. During the physical
examination you notice that while she stands with her feet on the ground, her heel is in
varus but her arch appears normal.
a) What may be the cause of the pain in her foot?
Overstretching of ligaments and stress across foot joints. Muscle issues
 Varus heel, tight tibialis posterior, weak tib anterior, and toes or hallucis longus
tightness.

Be familiar with compensated/uncompensated forefoot varus/valgus.

b) A PT is using a heel wedge on the patient’s foot to analyze the position of the
midfoot and forefoot. Explain why assessing foot pronation/supination just by
the relative position/movement of the calcaneus could be problematic.

It would be problematic because PT wouldn’t be considering the position of the

midfoot and forefoot
Neglecting looking at two other axis

False to assume by looking at just the calcaneus, need to look if they are
plantar flexing, adducting, supinating

c) Is pes cavus or pes planus more difficult to treat?

Pes cavus is more difficult to treat because it might lead to clawing of the toes.
Also consider issues with orthotics.

Pes cavus harder to treat because it is harder to break an arch then build one.

4. In children with cerebral palsy, hyperactivity of the tibialis posterior is a frequent

problem. An 8 year old child has hyperactivity in his Tibialis Posterior throughout the
walking cycle, such that it overwhelms the synergistic actions of other muscles.
● What would you anticipate to be the position of the foot at initial contact –
throughout stance?
It will be in equino varus foot (weight on balls of feet and knees
together/valgus)
● On what surfaces of the foot would he be weight-bearing during stance?
Lateral side of the foot
● Weakening (via a surgical procedure) of Tibialis Posterior muscle might help to
improve this condition. Which muscles would you consider strengthening pre and
post-surgery?

Stretching the plantar flexors (like gastroc) will be hard as the patient is
stuck in plantarflexion.
Strengthening tibialis anterior, extensors and fibularis longus/ tertius/ brevis
Similar, more stretching and strengthening post-surgery

5. Post a picture of Anterior Drawer test with

1) Foot on the plinth

2) Foot off the plinth