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PODMED3 > wk 11- achilles/ ankle/RF pain > Flashcards

wk 11- achilles/ ankle/RF pain Flashcards

1
Q

types of achilles pain

A

midportion

insertional tendinopathy

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2
Q

achilles rupture

A

explosive activity with a loud crack and initial feeling of being kicked

more common in males

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3
Q

assessments for achilles rupture

A

calf squeeze test

simmonds test

thompsons test

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4
Q

treatment for achilles rupture

A
  1. referral to orthopeadic surgery for repair
  2. conservative rehab
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5
Q

what tendon is medial to the achilles

A

plantaris tendon

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6
Q

stages of achilles tendinopathy

A

stage 1- reactive tendinopathy: short term adaption to overload. non inflammatory proliferative response, tendon thickens

this can reverse back to normal if given time to rest between loading and overload is reduced

stage 2- tendon dysrepair
tendon attempts to heal with matrix breakdown (increase number of cells and vascularity on ultrasound)

stage 3- degenerative tendinopathy
progression of matrix disorganisation/breakdown, cell changes and neovascularisaton

if load not reduced, rupture as the tendon is structurally unable to transmit tensile loads

reactive on degenerative:
structurally normal portion of tendon may go in and out of a reactive response

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7
Q

clinical features of mid portion achilles tendinopathy

A

pain/stiffness 2-6cm above posterior calc

burning pain

pain increased with activity and relieved with rest

thickening palpated

negative calf squeeze test

postitive royal london hospital test - pain absent on max dorsiflexion

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8
Q

what is there little evidence on correlation with achilles tendinopathy

A

STJ pronation

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9
Q

intrinsic and extrinsic risk factors for achilles tendinopathy

A

int:
1. weak plantarflexion strength
2.increased/reduced dirsflexion ROM
3. reduced knee flexor strength
4. poor tendon structure

ext:
1. increased tendon loading with activities
2. FW
3. surface

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10
Q

imaging for achilles tendinopathy and what to look for

A
  1. US
    -tendon thickening
    -neovessels
    -hypoechogenic
    -disorder fibres
    -tissue gaps
    -fluid
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11
Q

management of achilles tendinopathy

A
  1. alfredsons protocol
    3x15 reps twice a day, every day for 12 weeks

knee straight and bent knee lowering on injured leg

can progress with weight

if theres improvement continue for 6-12 months

  1. 4 stage achilles rehab program
    - isometric calf raise 45sec, 4-5reps with 2 mins rest. completed 2-3 times a day
    -isotonic calf raise, slow eccentric. twice a week
    -energy storage, slow skipping 3 times a week
    -energy storage and release
  2. if theres no improvement
    -modify load/activtiy
    -consider other modalities like electrotherapy,massage, GTN patch
    -surgery last resort
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12
Q

what can plantaris do to achilles

A

compresses achilles
or ensheafed in tendon

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13
Q

how to know if theres plantaris involvement in achilles pain

A

-pain more medial ad proximal
-pain aggrevated by loading in dorsiflexion

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14
Q

what type of tendinopathy is most common

A

mid portion

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15
Q

how does insertional achilles tendinopathy occur

A

excessive tendon load with compression against the calc

excessive dorsflexion with high tensile loads

increased compression when pushing against resistance

running uphill

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16
Q

clinical features of insertional achilles tendinopathy

A

palaption of posterior calc causes pain

there may be pain on dorsiflexion

swelling

royal london test

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17
Q

management of insertional achilles tendinopathy

A
  1. deload
    2.avoid barefoot/ heel raises
    3.staged loading rehab (alfred or 4 stage) avoiding dorsiflexion (not on step)
  2. dont over stretch
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18
Q

bone pathology of the ankle/RF

A

talar dome lesion

calcaneal apophysitis

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19
Q

soft tissue pathology of ankle and RF

A

post tib tendinopthy
post tib dsfunction
peroneal tendinopthy
tib ant tendinopathy
FHL tendinopthy
achilles tendinopathy
retrocalcaneal bursitis

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20
Q

joint pathology of ankle

A

ankle impingement anteiror/posteiror

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21
Q

neural/vascular pathology of ankle

A

tarsal tunnel syndrome

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22
Q

talar dome lesion is what

A

osteochondritis dissecans of the talar dome

(subchondraol bone and articular cartilage separate from underlying bone)

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23
Q

how does talar dome lesions occur

A

trauma/injury (inversion ankle sprain that doesnt improve with conservative treatment)
vascular failure
genetic predisposition

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24
Q

posterior medial talar dome lesions occur by

A

foot plantarflexed during inversion

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25
Q

anterolateral talar lesion occurs when

A

foot is dorsiflexed

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26
Q

clinical features of talar dome lesion

A

pain around anterior ankle when plantarflexed
swelling
stiffness/ reduced ROM
popping, clocking, locking (loose body)

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27
Q

management of talar dome lesion

A
  1. immobilise in NWB cast 3-4weeks
  2. then immobilise in CAM walker 6-10 weeks
  3. surgery
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28
Q

what is post tib tendon dysfunction

A

loss of dynamic and static support of MLA, hindfoot, ankle (not just post tib)

dynamic:
-plantar aponeurosis
-post tib tendon
-plantar intrinsic muscles

static:
-spring lig
-superficial deltoid lig
-long and short plantar lig
-plantar aponeurosis

flat foot deformity

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29
Q

risk factors of PT dysfunction

A

-40years and more
-woman
-obese
-hypertension
-diabetes
-trauma or surgery to medial aspect of foot

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30
Q

patho of PTTD

A
  • existing flatfoot
  • increased gliding resistance of PTT
    -everted hindfoot unlocks midtarsal joint during midstance/terminal and heel rise
    -increased strain on supportive ligamnents and post tib
    -attenuation and rupture of PTT
    -rupture of spring lig, deltoid and plantar ligs
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31
Q

soemone with long standing flexible flat foot is prediosposed to

A

PTTD

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32
Q

stages of PTTD

A

1- tensosynovitis (flexible)
2- atteuation or rupture (flexible, may not be able to heel raise)
3- complete rupture (rigid)
4- valgus talo crural joint (rigid)

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33
Q

assessing PTTD

A

-double and single leg raises
look for heel heights and supination
if unable to perform heel raise it indicates stage 2 PTTD

-jacks test- windlass mechanism

-assess flexibility of rearfoot
inversion and eversion
if rigid then its a sign of stage 3/4 PTTD

-assess NWB muscle strength

-supination lag: getting patient to plantarflexed and bring soles together (less movement in PTTD)

34
Q

treatment for PTTD depends on

A

stage

35
Q

stage 1 PTTD management

A
  1. reduce inflammation
  2. immobilise (CAM walker, bracing, taping low dye
  3. footwear modifications (medial wedge, flares)
  4. orthoses
36
Q

stage 2 PTTD management

A
  1. immobilise (CAM walker 1-6 weeks
  2. custom foot orthoses - kirby skive, inverted poor
  3. custom hinge AFO (richie brace)
  4. footwear modifications
  5. rehab program
37
Q

stage 3 PTTD management

A
  • if no severe DJD (degenerative joint?) in ankle and hindfoot then restricted hinge AFO (richie brace)

-if there is Gauntlet with flexible AFO shell

38
Q

stage 4 PTTD mangement

A

gauntlet with rigid AFO shell

39
Q

what does a richie brace do

A

treats PTTD
foot drop
chronic ankle instability

types
standard
dynamic
gauntlet

40
Q

FHL tendinopathy caused by

A

repetitively going onto toes when plantarflexion is required

wearing shoes too big

walking down hill (gripping of toes)

associated with posterior impingmenet syndrome

enlargement of os trignonum compresses FHL

FHL runs between sesamoids plantar 1st MTPj

41
Q

clinical features of FHL tendinopathy

A

-pain with toe off or forefoot loading
-pain when landing
-aggrevated with resisted flexion or passive stretch into dorsiflexion

42
Q

management of FHL tendinopthy

A
  1. rest
  2. FHL isometric/isotonic strength
  3. soft itssue therapy
  4. orthotics
  5. taping
43
Q

peroneal tendinopathy

A

most common lateral ankle pain

causes
1. inversion injury (overstretch of tendon)
2. overuse due to RF eversion/ lat deviated STJ
3.tight ankle plantar flexors causing an increase load on lateral muscles
4. overuse due to dancing, jumping, soft footwear

44
Q

types of peroneal tendinopathy

A
  1. posterior to lateral malleoli (most common)
  2. peroneal trochlea
  3. plantar surface of cuboid
45
Q

clinical features of peroneal tendinopathy

A

lateral ankle or lateral heel pain worsens with activity
tenderness along peroneal
pain on passive inversion and resisted eversion
tight calf muscles

46
Q

management of peroneal tendinopathy

A
  1. immobilise/rest (CAM walker)
  2. soft tissue therapy/manual therapy
  3. lateral heel wedge
  4. eccentric strength with eversion
47
Q

tib ant tendinopathy

A

overuse of tib ant due to
1. restriction in ROM
2. stiffness in ankle
3. walking/running downhill

48
Q

clinical features of tib ant tendinopathy

A

-pain, swelling, stiffness in anterior ankle
-occasional crepitus
-aggrevated by walking running up hills or stairs
-tenderness along tendon
-resist dorsiflexion and eccentric inversion gives pain

49
Q

management of tib ant tendinopathy

A

1 rest
2. soft tissue theray, amnual therapy
3. address cause
4. eccentric strengthening

50
Q

what is ant ankle impingment

A

common in football and ballet dancers

soft tissue or bone compresses between the talus and tibia during dorsiflexion

51
Q

clinical features of ant ankle impingement

A

vague discomfortable at front of ankle which becomes sharper and more localised with dorsiflexion

lunge test is painful and typically shoes limited range

52
Q

management of ant ankle impingement

A
  1. heel raise
  2. rest- limit dorsiflexion
  3. NSAIDs
  4. manual therapy
  5. taping
  6. arthroscopic removal if exostosis
53
Q

what is posterior ankle impingement

A

soft tissue or bone compresses between tibia and superior aspect of calc

common in footballer, ballet dancers

can occur in enlarge posterior tubercles or ostrignonum

54
Q

sinus tarsi syndrome

A

interosseous ligaments, synovial membrane, blood vessels, fat and connective tissue located in this area that can be compressed and cause synovitis/inflammation

55
Q

clinical features of sinus tarsi syndrome

A

vague, pain near anterior/lateral mall
pain worse in morning and improves with activities
pain worse on uneven surfaces
pain on passive eversion and inversion of STJ
tenderness on palpation and over ATFL

56
Q

management of sinus tarsi syndrome

A
  1. rest
  2. NSAIDs, ice
  3. movilisation of STJ
  4. CSI in sinus tarsi
  5. address biomechanics
  6. proprioceptive and strength trainign
57
Q

calc stress fracture clinical features

A

-intense diffuse heel pain along medial and lateral aspect of posterior calc
-pain worse wb and activity
-persistent night pain
-positive squeeze test or pain on direct compression

58
Q

managament of stress fracture of calc

A
  1. immobilise (CAm walker, soft cast) 4-8weeks
  2. rehab strength program
  3. heel cushions
  4. assess biomechanics, BMD, training load, footwear, etc
59
Q

what is plantar heel pain (plantar fasciopathy)

A

overuse condition of the plantar fascia at its attachment to the calc

60
Q

risk factors for plantar fasciopathy

A
  1. running (cavus foot and hindfoot in runners)
  2. BMI
  3. standing time/walking on hard surfaces
  4. impactful daily activities
  5. high arch
  6. reduced ankle dorsflexion
  7. hammy tightness (8x more likely to have heel pain)
    8.leg length difference
61
Q

patho of plantar fasciopathy

A
  1. reduced neuromuscular activity in the muscles in the foot leading to increased loads of the fascia

or

  1. mechanical deficiency in the fascia which makes it unable to take normal levels of stress
62
Q

clinical features of plantar fasciopathy

A
  • heel pain after increase in WB actvitiy
    -pain worse in morning when getting out of bed
    -pain on palpation of proximal insertion of fascia
    -positive windlass test
    -negative tarsal tunnel test
    -abnormal FPI score
    -BMI
63
Q

plantar medial heel pain

A

most noticeable with initial steps after inactvitiy and worse following prolonged wb

64
Q

ddx for heel pain

A

spondylarthritis
fat pad atrophy
plantar fibroma
baxters nerve entrapment
a fascial tear
heel spur
calc stress fracture

65
Q

what is a common radiographic finding in heel pain

A

calc spurs

66
Q

what is the thickness looking for in US for fascia

A

> 4mm

67
Q

management of plantar heel pain (1st)

A

3 teirs

1st:
-padding and strapping, low dye
-stretching fascia and calf
-footwear advice with cushioning and support
-NAIDS
-arch support
-prefab with heel cup, pad

68
Q

2nd tier PHP

A

AFTER 6 WEEKS

2nd tier:
- corticosteroid injection
-dry needling for lower limb muscles
-custom orthotics
-immobilisation
-high load strength (heel raises with towel under toes)

69
Q

3rd tier

A

after 6 months

3rd tier
-night splint / strassburg sock
-shockwave therapy
-surgery plantar fasciomoty fasciectomy

70
Q

fat pad syndrome

A

damage, atrophy, inflammation, contusion

common in elderly (50yrs) and diabetes

71
Q

clinical features of fat pad syndrome

A

deep, non radiating pain
WB portion of calc tubercle
barefoot makes worse
pain on palpation of central plantar aspect of heel

72
Q

management of fat pad syndrome

A
  1. NSAIDs/paracetamol
  2. footwear modifications to reduce plantar pressure (aperture)
  3. silicine heel cup
  4. reduce WB activities
  5. footwear advice (cushioning)
  6. taping- heel lock, x arch taping
73
Q

what is piezogenic papules

A

minor herniation of adipose tissue that surrounds the calc

may be associated with ehlers dnalos sydnrome

common in long standing, marathon runners, weight lifters

74
Q

managament of piezogenic papules

A
  1. corticosteriod injection
  2. deoxycholic acid injection (breaks down cells in fatty tissue)
  3. reduce standing
  4. compression stockings
  5. soft heel cups
75
Q

what is baxters nerve entrapment

A

entrapement of the 1st branch of lateral nerve which innervates abductor digiti minimi muscle

can be entrapment between deep fascia of adductor hallicus and quadratus plantae or anterior calc near the medial calc tubercle

76
Q

clinical features of baxters nerve

A

-medial/plantar heel pain
-worse at night and is constant
-tenderness over medial aspect of plantar heel
-inability to abduct 5th toe
-no sensory deficits

77
Q

management of baxters nerve

A
  1. NSAIDS
  2. shock absorbing innersoles
  3. MLA support
  4. steroid injections

if no change after 6 months
5. surgery

78
Q

tarsal tunnel syndrome

A

tibial nerve compression in the tunnel

uncommon but occurs from fracture or dislocation of the medial ankle area

79
Q

clinical features of tarsal tunnel

A

-aching, burning, numbness
-radiating pain in calf
-worse at night and standing
-prominent tinel’s sign
-dorsiflexion/eversion test which stresses tibial nerve

80
Q

management of tarsal tunnel

A
  1. NSAIDs
  2. footwear modifications
  3. CSI
  4. surgery
81
Q

what is sondyloarthrophy?

A

PODMED3 (9 decks)

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