Updated: 6/8/2021

Foot Muscle Forces & Deformities

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Questions
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Evidence
12
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Videos / Pods
2
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Cases
1
Topic
Images
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  • Introduction
    • Simple Deformities
      Deformity
      Strong Muscle
      Weak Muscle
      Equinus
      Gastroc-soleus complex 
      Dorsiflexors
      Cavus
      Plantar fascia, intrinsics
      Dorsiflexors
      Varus
      Posterior tib, anteiror tib
      Peroneal brevis
      Supination
      Anterior tibialis 
      Peroneus longus 
      Flatfoot
      Peroneus brevis
      Posterior tibial tendon
    • Complex Deformities
      Deformity
      Strong Muscle
      Weak Muscle
      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 (24)
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(OBQ15.211) A 42-year-old male presents with chronic plantar foot pain. The pain is worst when he wakes up, and remains persistent throughout his workday. Which of the following findings is an indication for gastrocnemius recession?

QID: 5896
1

A Silverskjold test demonstrates 10 degrees less than neutral with the knee in extension versus 10 degrees beyond neutral with the knee flexed

85%

(2860/3360)

2

A Silverskjold test demonstrates 5 degrees of ankle dorsiflexion with the knee in extension, which does not change with the knee flexed.

9%

(302/3360)

3

Persistent pain despite three months of rigorous physical therapy

5%

(156/3360)

4

Flexible pes planovalgus

0%

(15/3360)

5

A positive "too many toes" sign

0%

(14/3360)

L 2 A

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

QID: 3285
FIGURES:
1

Silfverskiöld test used to differentiate gastrocnemius tightness from achilles tendon contracture

91%

(3354/3672)

2

Thompson test used to differentiate soleus tightness from achilles tendon contracture

0%

(13/3672)

3

Coleman test used to differentiate soleus tightness from achilles tendon contracture

1%

(31/3672)

4

Silfverskiöld test to differentiate soleus tightness from achilles tendon contracture

6%

(224/3672)

5

Thompson test to differentiate gastrocnemius tightness from achilles tendon contracture

1%

(37/3672)

L 1 C

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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?

QID: 1217
1

Gastrocnemius fascia lengthening (Strayer) procedure

16%

(336/2138)

2

Split anterior tibial tendon transfer (SPLATT)

14%

(310/2138)

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

10%

(205/2138)

4

Fractional lengthening of the tibialis posterior

0%

(7/2138)

5

Ankle foot orthosis (AFO) with physical therapy

59%

(1268/2138)

L 2 C

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Evidence (12)
VIDEOS & PODCASTS (3)
CASES (1)
EXPERT COMMENTS (8)
Private Note