ankle Flashcards
tibial stress fracture
- most common stress fracture location
- women>men
- military, runners >25mpw
- history: shin pain with wb, recent changes with training
- TTP anterior aspect of tibia, edema, tuning fork test
- diagnostic: MRI gold standard
- management: activity reduction
- prognosis: delayed treatment leads to prolonged return to activity
ottawa ankle rule
- TTP along distal 6cm of posterior edge of tibia or tip of medial malleolus
- TTP along distal 5cm of posterior edge of fibular or tip of lateral malleolus
- inability to bear weight both immediately and in ED for 4 steps
ottowa foot rule
- ttp at base of 5th met
- ttp at navicular
- inability to bear weight both immediately and in ED for 4 steps
avulsion fracture
- injury or sports
- participation in sports is risk factor
- violent muscle contraction, may hear or feel pop
- painful passive stretch or active contraction of involved muscle, pain on palpation
- diagnostic: radiography
- non surgical or surgical
- prognosis is good.
venous thomboembolizm
- commonly seen in patients with cancer, following surgery, trauma, or immobilization
- located proximal to bifurcation of the popliteal vein, considered to be more dangerous
- located distal to bifurcation of popliteal vein
risk factors for PAD
- male
- age >60
- intermittent claudication
- abnormal pulses in both feet
- ischemic heart disease
- hx of smoking
ABI
ankle systolic BP/bracial systolic BP
- normal: 1-1.3
- ABI less than .9 diagnostic for PAD
mild: .7-.9
mod: .4-.7
severe: <.4
iliac artery occlusive disease
intermittent claudication
- buttocks: aorta, common iliac artery, hypogastric
- thigh: external iliac, common femoral artery
leriche syndrome
- decreased femoral pulses
- muscle atrophy
- impotence: indicates internal illiac, pudendal, obturator arteries
knee OA by altmin
3/6
- age >50
- morning stiffness <30 min
- crepitus
- bony tenderness
- bony enlargement
- no palpable warmth
SN: .95
SP. .69
lateral ankle sprain
- least stable in loose packed position: PF with inversion
- progression of severity from ATF Lto CFL to PTFL
medial ankle sprain
- less common due to decreased eversion ROM and bony architecture (5-10% of all ankle sprains)
- more severe
- potential for mortise instability
- medial malleolar fracture
- localized pain over the deltoid
- positive eversion (talar tilt) test
syndesmotic high ankle sprain
- even more rare
- injury to ATFL ligament and/or syndesmosis
- hyper dorsiflexion
- rotation and PF
- recovery >6 months
- often surgical candidate
special tests
- syndesmotic squeeze
- ER stress test
- fibular translation test
grade 1 lateral ankle sprain
- mild symptoms
- likely kept playing
- microscopic tearing of ATFL
- no functional loss or instability
- recovery time: 2-10 days
grade 2 lateral ankle sprain
- moderate functional loss
- involves ATFL and CFL
- may have initially walked it off
- diffuse swelling/tenderness
- recovery time 10-30 days
grade 3 lateral ankle sprain
- unstable multi-ligamentous sprain
- anterior capsular involvement
- unable to fully WB
- diffuse edema/tenderness
- frequent concomitant fracture
- recovery time 30-90 days
anterior drawer for ankle
- test ATFL
- better diagnostic accuracy 5 days post injury compared to 2 days post injury
(+) pain or laxity - sensitive test
talar tilt test
Patient is seated with foot and ankle unsupported. The foot is positioned in 10-20 degrees of plantarflexion. The distal lower leg is stabilized with one hand just proximal to the malleloi and the hindfoot is inverted with the other hand. The lateral aspect of the talus is palpated to determine if tilting occurs. The laxity is compared to the contralateral side.
- tests CFL
- SN: .67 SP: .75
chronic ankle instability
- residual symptoms that include feelings of giving way and instability as well as repeated ankle sprains, persistent weakness, pain during activity and self-reported disability
- mechanical instability (laxity, joint changes)
- functional instability (altered neuromuscular control, strength deficits, postural control deficiency)
potential objectives of using a foot orthosis
- shock attenuation and absorption
- provide cushion to tender areas of foot
- relieve areas of abnormal increased plantar pressure
- provide support, and protection of a healed fracture site
- minimize shear forces
- attempt correction of flexible deformities, or to provide support and stability
- restrict motion of painful joints
- try and accommodate rigid deformities.
accommodative (soft) foot arthoses
- designed to provide cushioning and protection
- include insensate foot and fixed deformites
accommodative (soft) foot orthoses
- designed to protect and cushion
- made for insensate foot and fixed deformities
rigid foot orthoses
- designed to provide arch support and control for flexible deformities, are often durable
- offer minimal cushion, shock absorption, and protection
- not easily adjustable
semirigid foot orthoses
- most frequently used
- cushioning, shock absorption, protection, weight redistribution, support, and control for flexible deformities
- used to offload areas subjected to abnormal high pressure
- great for neuropathic patients
off shelf orthoses
- good for cushioning and shock attenuation in those without deformity, neuropathy, or ulcers
ankle foot orthoses
- double upright construction attached to shoe or molded ankle foot orthoses
- can be fixed or articulated
- to limit ankle motion: trim lines should extend anteriorly to level of midline malleoli
- to control subtalar or midtarsal motion while maintaining some ankle motion: trim line should end posterior to malleoli
dynamic AFO
- provides proprioceptive feedback from ground and can help strength calf muscle
- goal is support while providing normal ORM
hinged AFO
- foot drop
- dorsiflexion assist functional AFO
can add plantar flexion stop in severe foot drop
arizona brace AFO
- designed for conservative management of posterior tibial tendon dysfunction or other hindfoot deformities
- maintain hindfoot in neutral
- has reduced height
- more bulkier and difficulty fitting inside shoes
night splints for plantar fasciitis
- keep ankle in DF
- great combined with anti-inflammatories, viscoelastic heel pads, and stretching program of gastrocsoleus complex
posterior tibial tendon dysfunction
- goal is to attempt restoring the medial arch and to eliminate pronation
morton neuroma
- typically between 3-4 met head
- metatarsal pad: splays metatarsal heads to relieve pressure
- first line of treatment is shoe modification to use shoe with low heel and large toe box
exercise
mid portion Achilles tendinopathy 2018
LVL A
- should use mechanical loading, eccentric exercise, or heavy load slow speed exercise program to decrease pain and improve function for patients with midportion achilles tendinopathy
LVL F
- patients should exercises at least twice weekly
stretching
mid portion Achilles tendinopathy 2018
LVL C
- may use stretching of PF’s with the knee flexed and extended
neuro-reeducation
mid portion Achilles tendinopathy 2018
LVL F
- may use NM exercises targeting lower extremity impairments
manual therapy
mid portion Achilles tendinopathy 2018
LVL F
- may consider joint mobilization and STM to increase ROM
patient education: activity modification
mid portion Achilles tendinopathy 2018
LVL B
- for non acute, patients should advise that complete rest is not indicated and they should continue with recreationally activity within pain tolerance
patient counseling
mid portion Achilles tendinopathy 2018
LVL E
- theories supporting use for PT and role of mechanical loading
- modifiable risk factors (BMI, shoewear)
- typical time course for recovery
heel lifts
mid portion Achilles tendinopathy 2018
LVL D
- no recommendation
night splints
mid portion Achilles tendinopathy 2018
LVL C
- should not use night splints
orthoses
mid portion Achilles tendinopathy 2018
LVL D
- no recommendation
taping
mid portion Achilles tendinopathy 2018
LVL F
- should no use therapeutic elastic tape to reduce pain or improve functional performance
- may use rigid taping to decrease strain on the achilles tendon and alter foot posture
low level laser therapy
mid portion Achilles tendinopathy 2018
LVL D
- no recommendation
iontophoresis
mid portion Achilles tendinopathy 2018
LVL B
- should use iontophoresis with dexamethasone to decrease pain and improve function in acute
dry needling
mid portion Achilles tendinopathy 2018
LVL F
- may use combined therapy of dry needling and eccentric exercise for individuals with symptoms greater than 3 months and increased tendon thickness
dry needling
mid portion Achilles tendinopathy 2018
LVL F
- may use combined therapy of dry needling and eccentric exercise for individuals with symptoms greater than 3 months and increased tendon thickness
diagnosis of acute lateral ankle sprain
lateral ankle ligament sprains 2021
LVL B
- anterolateral drawer test
- anterolateral talar palpation
- traditional anterior drawer test
primary prevention of first time lateral ankle sprain
lateral ankle ligament sprains 2021
LVL A
- should recommend use of prophylactic bracing to reduce risk
LVL C
- may recommend use of prophylactic balance training to those who have not experienced LAS
secondary prevention of recurrent LAS
lateral ankle ligament sprains 2021
LVL A
- should prescribe prophylactic bracing and use proprioceptive and balance-focused therapeutic exercise training programs
acute and postacute LAS: protection
lateral ankle ligament sprains 2021
LVL A
- should advise patients to use external supports and to progressively bear weight on affected limb
- in more severe injuries, immobilization ranging from semi-rigid bracing to below knee casting may be indicated for up to 10 days post injury
acute and postacute LAS: TE
lateral ankle ligament sprains 2021
LVL A
- should include protected AROM, stretching, neuromuscular training, postural re-ed, balance
LVL D
- conflicting evidence as to the best way to augment unsupervised components of HEP
acute and postacute LAS: occupational and sports related training
lateral ankle ligament sprains 2021
LVL B
- should implement return to work schedule and use brace early in rehab
acute and postacute LAS: manual therapy
lateral ankle ligament sprains 2021
LVL A
- should use manual such as lymphatic drainage, active and passive joint mobilization, AP talar mobilization within pain free movement along with therapeutic exercise
acute and postacute LAS: acupuncture
lateral ankle ligament sprains 2021
LVL D
- conflicting evidence
acute and postacute LAS: modalities
LVL C
- cryotherapy: may us intermittent following exercise
LVL C
- diathermy: may use pulsating shortwave diathermy for reducing edema and gait deviations
LVL E
- electrotherapy: evidence for and against
LVL C
- low level laser: may use to reduce pain in initial phase
LVL A
- ultrasound: should not use ultrasound
acute and postacute LAS: NSAID’s
lateral ankle ligament sprains 2021
LVL C
- may use NSAID’s to reduce pain and swelling
CAI: external support
lateral ankle ligament sprains 2021
LVL B
- should not use bracing or standing as stand alone to improve balance or stability
CAI: exercise
lateral ankle ligament sprains 2021
LVL A
- should prescribe proprioceptive and neuromuscular therapeutic exercise to improve dynamic postural stability and patient-perceived stability
CAI: manual therapy
lateral ankle ligament sprains 2021
LVL A
- should use graded joint mobilizations, manipulations, NWB and WB mobilization to improve ankle DF and dynamic balance for short term
CAI: dry needling
lateral ankle ligament sprains 2021
LVL C
- may use dry needling of fibularis muscle in conjunction with proprioceptive training to reduce pain and improve function
CAI: combined treatments
lateral ankle ligament sprains 2021
LVL B
- may use multiple interventions to supplement balance training including exercise and manual therapy
posterior tibial tendon dysfunction
- common cause of painful acquired flatfoot deformity in adults
- loss of hindfoot inversion, inability to negotiate uneven ground, climb, descend stairs
stage I PTTD
- pain and swelling along tendon
- length of tendon is normal, patient can perform SL heel raise
- flatfoot deformity is minimal
- alignment of hindfoot forefoot complex is normal and subtalar joint remains flexible
stage II PTTD
- unable to perform SL heel raise due to attenuation or disruption of PTT
- tendon is enlarged and elongated
- foot has adopted pes planovalgus position with collapse of medial longitudinal arch, hindfoot valgus, and subtalar joint eversion, forefoot abduction
- subtalar joint is flexible
- ankle is in equinus
stage III PTTD
- patient unable to do SL heel raise
- severe flatfoot deformity
- pes planovalgus deformity is fixed and lateral subluxed navicular cannot be reduced
medial tibia stress fracture
- present with medial shin pain aggravated with exercise
- tenderness localized in posteromedial border of lower third
anterior cortex of tibia stress fracture
- critical due to prone to delayed union, nonunion, and complete fracture
- can take 4-6 months to heal
fibular stress fracture
- result from muscle traction and torsional forces
- in distal third fibula commonly
medial malleolus stress fracture
- several week history of mild discomfort followed by acute episode that results in seeking medical attention
talus stress fracture
- localized tenderness over medial or lateral aspects of calcaneous
- 6-8 weeks to heel
- can run after 6 weeks
cuboid and cuneiform stress fractures
- rare
navicular stress fracture
- most commonly occurs in central third
- pain is insidious and nonspecific
- nonweightbearing for 6 weeks
metatarsal stress fracture
- 1,3,4 are usually uncomplicated
- base of 2 are most common in ballet dances and require rest for 6 weeks
- most common 5th met is avulsion of tuberosity by peroneus brevis tendon
exertional compartment syndrome
- reversible ischemia secondary to noncompliant osseofascial compartment that is unresponsive to expansion of muscle volume that occurs with exercise
- presents as recurrent episodes of leg discomfort experienced at a give distance or intensity in running
- quality of pain is tight, cramplike, or squeezing ache over specific compartment
what can lead to increase in compartment pressure
- enclosure of compartmental contents in an inelastic fascial sheath
- increased volume of skeletal muscle with exertion due to blood flow and edema
- muscle hypertrophy as response to exercise
- dynamic contraction factors due to gait cycle
anterior compartment of leg
- contains extensor hallucis longus
- extensor digitorum longus
- peroneus tertius
- anterior tib
- deep peroneal nerve
45% of compartment syndrome
lateral compartment of leg
- peroneus longus and brevis
- superficial peroneal nerve
10% compartment syndrome
posterior compartment of leg superficial
- gastrocsoleus
- sural nerve
5% compartment syndrome
posterior compartment of leg deep
- flexor hallucis longus
- flexor digitorum longus
- posterior tib
- posterior tib nerve
40% compartment syndrome
medial tibial stress syndrome
- diffuse tenderness over posteromedial aspect of distal third of tibia
- increased valgus force on rear foot and excessive pronation that result in eccentric contraction of soleus and posterior tib muscles are causes
- other factors include excessive planus or cavus, tarsal coalition, lower extremity length inequality, muscle imbalance
treatment: rest and correction in training
- should avoid hill running and uneven surfaces
risk factors
plantar fasciitis 2014
LVL B
- limited DF
- high BMI in non athletic
- running
- work related weight bearing activities with poor shock absorption
manual therapy
plantar fasciitis 2014
LVL A
- should use joint and soft tissue mobilization, mobility and calf flexibility to decrease pain and improve function
stretching
plantar fasciitis 2014
LVL A
- should use plantar fascia specific and GS stretching to provide short term relief
- may use heel pads to increase benefits from stretching.
taping
plantar fasciitis 2014
LVL A
- should use antipronation tape for immediate pain reduction (3 weeks)
- can use elastic therapeutic tape applied to gastroc and plantar fascia for short term relief
foot orthoses
plantar fasciitis 2014
LVL A
- should use foot orthoses to support medial longitudinal arch and cushion heel to improve function and reduce pain for short to long term periods
night splints
plantar fasciitis 2014
LVL A
- should prescribe a 1-3 month program of night splints
physical agents
plantar fasciitis 2014
LVL D
- electrotherapy: should use MT over electrotherapy, can use iontophoresis for short term relief
LVL C
- low level laser: may use
- phonophoresis: may use
- ultrasound: do not use
footwear
plantar fasciitis 2014
LVL C
- rocker bottom shoe construction
- shoe rotation during work week
education for weight loss
plantar fasciitis 2014
LVL E
- may provide counseling
- may refer to appropriate healthcare practitioner
exercise and neuromuscular re-ed
plantar fasciitis 2014
LVL F
- may prescribe strengthening exercises and movement training to control pronation
dry needling
plantar fasciitis 2014
LVL F
- cannot recommend
syndesmotic articulation 3 major ligaments
anterior inferior TFL
posterior inferior TFL
interosseous ligament
tests for high ankle sprain
- external rotation test
- squeeze test
- point test
- dorsiflexion maneuver
- one legged hop test
average cadence
101-122 step per min
most common nerves entrapped in lower leg
common peroneal, superficial peroneal, saphenous
superficial: dancers, athletes
common: runners and cycling
peroneal tendinitis
treatment includes NSAID’s, lateral heel wedge, PT and possible immobilization
painful os peroneum syndrome
- NSAID, lateral heel wedge, PT and immobilization
