(2) Lecture 12: Foot and Ankle Problems 2.0 Flashcards
Subungual Hematoma
- bleeding underneath toenail = pressure + pain
- common in distance running + squash b/c of deceleration (toe hits end of toe box)
Can also be acute
- drop weight on it, get stepped on
Treatment of Acute Subungual Hematoma
- need to evacuate blood to decrease pressure
- done w/ sterile heated paper clip
- use pliers to hold clip
- press into nail = blood will release
- new nail will grow underneath and push old nail off
Prevention of subungual hematoma
PAD FOREFOOT = holds foot back
Ingrown Toenail
- more common in MALES
- LARGE TOE is most often affected
- inflamed skin grows over lateral nail fold
- usually result from LATERAL pressure of poorly fitting shoes, improper trimming or repeated trauma
Prevention of Ingrown Toenail
Proper Trimming
- Trim weekly by cutting STRAIGHT across
- Avoid rounding so margins don’t penetrate tissues on side
- Should be left long enough to clear underlying skin, but not too much that it pushes into sock
Ingrown Toenail Treatment for Mild to Moderate cases
- soak in warm water to make tissue soft
- tease tissue back, away from nail
- take strand of cotton ball, wet it and roll until cylindrical
- tuck cotton along border of nail
Tape Method of Treatment for Ingrown Toenail
- place one end of tape along the tip of lateral nail fold on affected side + tuck it slightly inside nail fold
- pull nail fold gently outward to make insulated space btwn side of nail and nail fold + attach tape to side od big toe
- then fix other end of tape to toe pad w/o stretching the tape
Ankle stability comes from…
- shape of bones
- passive stabilizers (capsule + lig)
- dynamic stabilizers (muscles)
Ankle joint
Talocrural joint
- ankle mortise is U shaped at top of talocrural jt
Made up of
- lower end of tibia
- medial malleolus (tibia)
- lateral malleolus (fibula)
Malleoli
Lateral malleolus is LONGER and more posterior than medial
Talus
- NO muscles that attach to it
- convex on top and concave on sides (better articulation + plantar/dorsiflexion)
- trochlear surface (top) is wider anteriorly than posteriorly
With dorsiflexion, wider portion lies btwn malleoli
Fibula
with DORSIFLEXION
- fibula externally rotates and moves superiorly
- external rotation of fibula increases tension in structures that hold tibia and fibula together
- opposite happens in plantar flexion
How to rule out a fracture?
OTTAWA ANKLE RULES
Ankle X-Ray is needed if there is pain in malleolar zone and:
- bone tenderness at posterior edge or tip of lateral/medial malleolus
- inability to bear weight for 4 steps
Foot X-Ray is needed if there is pain in midfoot zone and:
- bone tenderness at base of 5th metatarsal or navicular
- inability to bear weight for 4 steps
Ottawa Ankle Rules
Used to rule out a fracture
External Rotation Test
ER Test
Used to diagnose FIBULAR FRACTURE
Indirect test: hand on medial side + externally rotate
Passive Stabilizers of Ankle
Ankle is surrounded by fibrous capsule
- thin + weak anteriorly + posteriorly
Talocrural joint is further strengthened medially and laterally by ligaments
- some communicated w/ capsule (ATFL, PTFL) and others don’t (CFL)
ATFL
Anterior Talofibular Ligament
- WITHIN capsule = increase swelling
- begins on lateral malleolus and travels anteriorly to talus
- WEAKEST of lateral ligaments
- increased strain in PLANTAR FLEXION + INVERSION as talus glides forward out of mortise
Anterior Drawer Test
Passive stabilizer special test
- used to determine damage to ATFL
- tested in SLIGHT PLANTAR FLEXION
- hold heel with one hand and shin just above ankle with other hand. Pull heel up and shin down
- positive test = foot slides forward and/or clunking sound as it reaches endpoint
Look for pain, laxity, endpoint
CFL
INVERSION + DORSIFLEXION
- extracapsular ligament
- neutral ankle position = starts on anterior part of lateral malleolus, below ATFL and runs downwards and backwards to attach to lateral calcaneus
- provides stability to lateral talocrural jt as it moves into DORSIFLEXION
- does not directly stabilize jt (stabilizes talocrural jt)
3.5x stronger than ATFL
PTFL
Posterior Talofibular Ligament
- WITHIN capsule = increase swelling
- starts on lateral malleolus and travels posteriorly around talus at 180 deg to ATFL
- primarily supports talocrural jt in DORSIFLEXION
- secondary support to talocrural jt
- some fibres communicate w/ ATFL
Deltoid ligament
EVERSION
- limits talar/subtalar abduction or lateral eversion
- broad
6 bands w/ variability
- ANTERIOR is tight in PLANTAR FLEX.
- middle portion in neutral
- POSTERIOR is tight in DORSIFLEX.
Talar Tilt Test
- to determine extent of injury to CFL (inversion) or DELTOID (eversion)
- foot at 90 degrees + calcaneus inverted (pain and excessive motion = CFL and possibly ATFL + PTFL tested)
- calcaneus everted = DELTOID ligament is tested
Dynamic Stabilizers of Ankle
- peroneus/fibularis longus and brevis may contract to slow down or stop movement in dangerous range
- controls rear for SUPINATION
- anterior muscles may contract to slow plantar flexion or supination
- medial muscles may prevent eversion sprains
Muscles involved w/ eversion sprain
- Peroneus longus
- Peroneus brevius
- Peroneus tertius
- Ext. Digitorum Longus
- Achilles Tendon
Muscles involved w/ inversion sprain
- Tib. Posterior
- Tib. Anterior
- Ext. Hallicus Longus
- Flex. Digitorum Longus
- Flex. Hallicus Longus
Ankle Sprains
- most common injury in sports
- 85% LATERAL, 10% SYNDESMOSIS, 5% MEDIAL
Properties of Ligaments
- wave or crimp across ligament
- injury is correlated to load-deformation curve
- 3 phases of curve: toe, liner, rupture region
Toe and Early Liner Region
- initial concave region
- normal physiological range of strain = 0-2% of length
Early linear region = 2-4%
- due to flattening of crimp
Repeated cycling of stretch in this range is REVERSIBLE
Ligament Sprains
- pathological irreversible ligament elongation
- intra and inter-molecular cross-link are disrupted until failure
Early part = mild/grade 1 (<50%)
Grade 2 = 50-80% fibre disruption (obvious laxity)
Grade 3 = 80-100% fibres (rupture zone)
When do ankle sprains usually occur?
- usually occur w/ loading + unloading
- CKC plantar flexion = talus is positioned anteriorly in ankle mortise
- main restraint for excessive anterior talar glide is ATFL
- while loaded, ankle is more stable in mortise
CKC
Closed Kinetic Chain
distal aspect is in contact w/ ground
OKC
Open Kinetic Chain
NOT in contact w/ ground
- ex. quad extension
Restraint for excessive anterior talar glide
ATFL
What ligament is first line of defense for ankle?
Depends on:
- mechanism (inversion vs eversion)
- ankle position (plantar flex. vs dorsiflex)
Deltoid Ligament Sprain
- LEAST common sprain
- MOI: EVERSION
- stability of medial ankle depends on deltoid lig supported by lateral malleolus
Symptoms of Deltoid Lig Sprain
- MOI: EVERSION
- pain on MEDIAL side of ankle
- instability w/ high grade sprain
Signs of Deltoid Lig Sprain
- pain w/ active + passive EVERSION
- pain, laxity, endpoint? findings w/ TALAR TILT test (EVERSION)
- possible pain w/ resisted inversion
- may have increased pronation
- pain on palpation over deltoid lig
ATFL Sprain
- MOST common sprain
- MOI: INVERSION in PLANTAR flexion
Symptoms of ATFL Sprain
- MOI: INVERSION in plantar flexion
- pain on LATERAL side of ankle, anterior to malleolus
Signs of ATFL Sprain
- pain w/ active + passive inversion in plantar flexion
- pain, laxity, endpoint? findings w/ ANTERIOR DRAW TEST
- possible pain w/ resisted eversion (dynamic stabilizers)
- pain on palpation over ATFL
CFL Sprain
- MOI: INVERSION in DORSIFLEXION
- 3.5x stronger than ATFL
Symptoms of CFL Sprain
- MOI: INVERSION in neutral to slight dorsiflexion
- pain on LATERAL side of ankle below malleolus
Signs of CFL Sprain
- pain w/ active + passive INVERSION in neutral
- findings w/ TALAR TILT test (INVERSION)
- possible pain w/ resisted eversion (dynamic stabilizers)
- pain over CFL ligaments
Subjective Assessment of Ankle Sprain
MOI
- inversion or eversion
- plantar flexed or dorsiflexed
Were you able to continue?
- unable to bear weight/gross instability
- able to walk = grade 2 injury
- able to run after = grade 1 injury
Did you hear or feel a pop/crack?
Swelling? How quickly?
- capsular vs non-capsular
Objective Assessment of Ankle Sprain
- swelling
- obvious deformity
Weight bearing
- static: equal pressure front/back, side to side
- dynamic: guarded/painful movement
Actions when ATFL is on tension
inversion + plantar flexion
Action when CFL is on tension
inversion + dorsiflexion
Action when anterior portion of DELTOID ligament is on tension
eversion + plantar flexion
Peroneus Longus action
eversion
Tibialis Posterior action
inversion
Ankle Special Tests
- manual muscle testing
- anterior drawer test
- talar tilt test
Always rule out fracture first
- external rotation
- Ottawa ankle rules
Positive Anterior Drawer Test
- significant anterior movement
- no endpoint
- minimal pain
Ankle Sprain Prognostic Indicators
- higher age, poor weight-bearing status
- NOT ACHIEVING FULL ROM WITHIN 2 WEEKS may be sign of accompanying injury
- medial pain on palpation + pain w/ dorsiflexion
Ankle Sprain Treatment
Inflammation/Destruction
- NSAIDs to reduce pain
- ice, compression + elevation
- protected injured tissue (crutches)
- optimal loading = maintain ROM in uninjured tissue
Ankle Sprain Treatment
Repair
- heat = increased blood flow
- begin ROM and idealize
- maintain strength of uninjured tissue
- gentle strengthening of injured tissue once ROM is achieved
- increase weight-bearing
- begin proprioception exercise
Ankle Sprain Treatment
Late Repair/Remodeling
- idealize strength of dynamic stabilizers
- continue w/ balance and coordination training
