Updated: 10/29/2019

Foot Muscle Forces & Deformities

Topic
Review Topic
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Questions
22
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Evidence
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Videos
1
Cases
1
https://upload.orthobullets.com/topic/7054/images/silverskiold_moved.jpg
Introduction
 
Simple Deformities
Deformity
Strong Muscle
Weak Muscle
equinus gastrocnemius-soleus complex dorsiflexors
cavus plantar fascia, intrinsics dorsiflexors
varus posterior tibialis and anterior tibialis peroneal brevis
supination anterior tibialis  peroneus longus
flatfoot peroneus brevis posterior tibialis
Complex Deformities
equinovarus + supination gastroc-soleus complex, posterior tibialis, anterior tibialis   peroneus brevis & longus
equinovalgus gastroc-soleus complex, peroneals posterior tibialis, anterior tibialis
calcaneovalgus foot dorsiflexors/evertors (L4 and L5) plantar flexors /inverters (S1 and S2)


Introduction
  • Equinovarus foot
    • most common deformity following stroke
      • use AFO and physical therapy for at least 6 months to await for possible neuro recovery
      • overactivity of the tibialis anterior, with contributions from the FHL, FDL, and tibialis posterior
    • treatment
      • nonoperative
        • AFO fitting
        • physical therapy
        • Phenol or botox injections
      • surgical
        • split anterior tibial tendon transfer (SPLATT)
        • flexor hallucis longus tendon transfer to the dorsum of the foot and release of the flexor digitorum longus and brevis tendons at the base of each toe
        • gastrocnemius or achilles lengthening 
  • Foot drop
    • Inability to dorsiflex at the ankle and/or toes
    • Commonly result from peroneal nerve palsy
      • Multiple etiologies
        • central nervous system (brain, spinal cord, nerve roots)
        • peripheral nervous system (sciatic nerve, peroneal nerve)
        • traumatic (knee dislocation, laceration, blunt trauma)
        • compressive (compressive mass, deformity correction)
        • systemic (diabetic polyneuropathy, mononeuropathy)
        • Iatrogenic (laceration, casting, positioning, surgical injury)
        • Mechanical (muscle debridement, tumor excision, etc.)
    • Presentation - variable depending on location of nerve injury
      • Motor
        • Loss of ankle/toe dorsiflexion (DPN)
        • Loss of ankle eversion (SPN)
      • Sensory 
        • Loss of first dorsal webspace sensation (DPN)
        • Loss of lateral leg/dorsal foot sensation (SPN)
    • Treatment
      • Nonoperative
        • Observation
        • AFO bracing
        • Therapy - stretching and supple joints
      • Operative
        • Acute injury
          • Laceration - repair, grafting, or nerve transfer
        • Chronic injury
          • Tendon transfer
            • Posterior tibial tendon transfer to lateral cuneiform +/- gastroc or Achilles tendon lengthening 
Physical Exam
  • Silfverskiöld test 
    • improved ankle dorsiflexion with knee flexed = gastrocnemius tightness     
    • equivalent ankle dorsiflexion with knee flexion and extension= achilles tightness
 

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Questions (22)
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(OBQ10.193) Which of the following best describes the physical examination test demonstrated in Figure A? Review Topic

QID: 3285
FIGURES:
1

Silfverskiöld test used to differentiate gastrocnemius tightness from achilles tendon contracture

91%

(2653/2928)

2

Thompson test used to differentiate soleus tightness from achilles tendon contracture

0%

(11/2928)

3

Coleman test used to differentiate soleus tightness from achilles tendon contracture

1%

(28/2928)

4

Silfverskiöld test to differentiate soleus tightness from achilles tendon contracture

7%

(192/2928)

5

Thompson test to differentiate gastrocnemius tightness from achilles tendon contracture

1%

(32/2928)

L 1

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SUBMIT RESPONSE 1
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(OBQ04.112) A 54-year-old male with Protein C deficiency sustained a stroke 3 months ago with subsequent left sided weakness. The patient's skin is intact with no sign of ulcerations or callosities. His left foot is developing a varus deformity secondary to a spastic tibialis anterior. His ankle has a 5 degree plantar flexion deformity due to a gastrocnemius contracture which improves with knee flexion (positive Silverskiold test). The patient has an intrinsic minus foot with supple claw toes present. Which of the following is the most appropriate next step in management? Review Topic

QID: 1217
1

Gastrocnemius fascia lengthening (Strayer) procedure

15%

(269/1739)

2

Split anterior tibial tendon transfer (SPLATT)

15%

(255/1739)

3

Flexor hallucis longus tendon transfer to the dorsum of the foot and release of the flexor digitorum longus and brevis tendons at the base of each toe

9%

(148/1739)

4

Fractional lengthening of the tibialis posterior

0%

(2/1739)

5

Ankle foot orthosis (AFO) with physical therapy

61%

(1058/1739)

L 2

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SUBMIT RESPONSE 5
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CASES (1)
Topic COMMENTS (6)
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