Ankle Flashcards
Chronic ankle instability
Functional: Repeated lateral ankle sprains or one severe
Mechanical: Laxity in ligamentous structure-Pes cavus and decreased proprioception, decreased strength, and postural control
Episodes of ankle giving away
Tx: Stabilize calcareous at heel strike Limit rearfoot inversion External support Strengthening and proprioception ex Surgical intervention
Syndesmosis sprain
High ankle sprain Excessive ER of talus and forced DF MOI: cutting, being fallen on Usually occurs with medial ankle sprain Maison-neuve fx: force enough to fx fibula
S/S: Painful WB AROM restricted all-DF worse PROM pain all RROM all directions Pain and pt tender on anterior aspect of ankle
ST: Kleigers External rotation Squeeze Dorsiflexion-compression test (no pain with DF while compression is applied)
Tx:
Immobilize and NWB
Surgery may be necessary
Medial ankle sprains
External rotation and eversion
Excessive pronation, hyper mobile, depressed medial longitudinal arch more predisposed
Knock-off fx: evaluate lateral malleolus
Pott’s fx: bimalleolar fx
S/S: Pain along medial jt line Localized swelling NWB Abduction and addiction painful
ST:
Talar tilt
Kliegers
Tx: RICE NWB NSAIDS and Analgesics Proprioception ex Inner heel shoe wedge insert Surgery may be required
Medial tibial stress syndrome
Overuse or weakness of post tib, flexor hallicus/digitorum, or soleus muscles Abnormal biomechanics Improper shoes Pes planus, hyper pronated foot Activity and playing surface Direct blow Varus foot, tight heel cord, hypermobile, pronated foot, supinated foot Women more than men Precursor to stress fx
S/S:
Diffuse Pain at post, medial aspect of tibia that has a broad span
Increased pain w/activity that subsides during but comes on after but will start to stay throughout
gradual onset
Tx: Control pronation-orthotics and changing shoes Rest, ice, stretching Ice massage Arch taping and tape around the area
Stress fx
Can affect the tibia, fibula, and talus
Persistent micro trauma
Hypermobile pronated feet-fibula
Pes cavus-tibia
Narrow tibial shaft, high degree of hip external rotation, osteopenia, osteoporosis
Dreaded black line-anterior cortex of tibia prone to nonunion fx common with jumping
S/S: Pain w/activity that's better w/rest at first Decreased muscle strength and cramping Creptius Night pain Pt tender to single spot Gradual onset Pain in shaft of bone Similar symptoms to MTSS and compartment syndrome
ST:
Percussion and bump
Tuning fork
Tx: X-ray won't show until healing has begun (3 wks) Rest-14 days Crutch or cast or boot WB once pain subsides After 2 weeks pain free patient can begin running again Orthotics Antiinflammatory Mesa
Achilles’ tendinitis
Inflammation of the tendon
Poorly vascularized-paratenon (vascularized structure that surrounds it)
Older and male more likely
Tenosynovitis causes fibrosis and scarring that can restrict the Achilles’ tendons motions within the tendon sheath
Osis-no inflammation, lost normal appearance, tendon overloaded because of excessive tensile stress from repetitive movements, degeneration of the tendons substance, micro tearing and necrotic areas, as a result of decreased blood flow
MOI: tibial Varum, calcaneal Valgum, hyper pronation, tightness of triceps surae and hamstrings, running mechanisms, increase in activity, type of shoe, surface, weak PF, increased DF or direct blow
S/S:
Soreness and stiffness that comes on gradually and continues to worsen until treated
Decreased gastroc and soleus complex flexibility and tightness
Generalized pain and stiffness about the Achilles
Uphill running or hill workouts make worse
Toe raises deficient
May present at beginning but go away with activity
Morning stiffness and discomfort when walking periods of prolonged sitting
Warm and painful to palpation, as well as thickened
Crepitus
Pain and burning radiating along the length of the tendon
Pt tender at inflamed site
Tx: Proper shoe wear and orthotics Flexibility exercises Ice, ultrasound, cross friction massage Strengthening of the gastroc-soleus Anti inflammatory Heel lifts Immobilization Cortisone injection-increased risk of rupture
Achilles’ tendon rupture
Forceful sudden contraction- stop and go action, pushing off action with knee completely extended
Most prominent in men over 30 and sedentary
Feeling of being kicked-audible pop
Running mechanics, training duration and intensity, type of shoe, running surface, biomechanics, hx of tendinitis, and deconditioning
Direct blow
Chronic inflammation and gradual degeneration
commonly at avascular zone (distal 2-6 cm)
S/S: sudden snap that felt like something kicked him or her in the lower leg Pain is immediate but rapidly subsides Pt tender, swelling, and discoloration Toe raising impossible Obvious indentation at the tendon site Unable to push off or heel raise Stiff leg gait-ER of extremity Defect may be felt with palpation PF still possible through peroneals, flexors, and post tib but contraction is diminished
ST:
Thompson test
Tx: Conservative-casting minimum 8 wks RICE, NSAIDS, analgesics, NWB-6 wks, walking boot for 2 wks DF night splints Rehab for 6 months-ROM Heel lift in both shoes Surgically
Subluxing peroneal tendon
Tear of superior peroneal retinaculum
Forceful sudden DF, eve, PF, and inv
Can be caused by a significant lateral ankle sprain-constant pain behind lateral malleolus
PF muscles become DF
Starts proximally and works distally
Flattened or convex fibular groove, pes planus, rear door valgus, recurrent ankle sprains, laxity of retinaculums
Common in older
Os peroneum-pain and dysfunction, fx, tear of tendon, increased lateral pain during single stance heel rise, inversion ST, and resisted PF
S/S:
Palpable subluxation with active PF and DF or eversion
Pain and dysfunction
Tear of tendon
Lateral instability with pain on post malleolus
Tx:
Surgery
Conservation-rehab, taping, felt pad over peroneal groove
Traumatic anterior compartment syndrome
Blow to ant lower leg
Edema and bleeding causes pressure that obstructs neurovascular network
Medical emergency
S/S:
Pain, pallor, pulselessness, paresthesia, paralysis
Pain w/ passive stretching
Numbness in web space of 1st-2nd toes and dorsal and lateral aspects of foot
Sensory changes not noticed until 1 hour-after 8 hours irreversible changes
Pain with activity, passive and resisted movement, decreased strength with DF
Drop foot gait
Tx:
Surgery
rehab to restore ROM and strength to LE
Profess to functional activities and RTP
Chronic and acute exertional compartment syndrome
Occurs secondary to anatomic abnormalities
Increased thickness of fascia that inhibits venous outflow but not arterial inflow
No prior symptoms or history of traumatic injury
MOI: herniation of muscle, failing fascia to increase, excessive hypertrophy, increased capillary permeability, postexercise fluid retention, decreased venous return, tibia fx, wearing high heels, knee braces, anticoagulants, and diabetes, low diastolic pressure
S/S:
Falling asleep
Once exercise stops s/s go away
Pain, pallor, pulselessness, paresthesia, paralysis
Pain w/ passive stretching
No injury
Numbness in web space of 1st-2nd toes and dorsal and lateral aspects of foot
Sensory changes not noticed until 1 hour-after 8 hours irreversible changes
Pain with activity, passive and resisted movement, decreased strength with DF
Drop foot gait
Tx: Confirm by checking pressure over 30 mm Hg Surgery rehab to restore ROM and strength to LE Profess to functional activities and RTP
Os trigonum
Bony outgrowth from posterior talus-Stedia’s process
First appears between the ages of 8-13 and fuses within 1 year of appearance
Traumatic when SP Fx or stress fx due to stress-forceful and excessive PF
S/S:
Talar compression: Inflammation Of posterior joint, ligaments surrounding the OT, fx of OT, pathology of SP
Painful PF, inversion, and pronation
Symptomatic after activity, repetitive microtrauma, or other inflammatory conditions
Fx: sudden onset of pain after forced PF or DF, swelling lateral or medial to Achilles, pt tender anterior to Achilles and posterior to talus, Painful PF
Tx:
Boot or cast with NWB or partial WB used until normal ambulation w/out pain
Orthotic or heel cup
Surgical removal of OT
Deep vein thrombophlebitis
Inflammation of veins associated with blood clots
Most common in surgical patients and sitting for a long time
Ruptured cyst, hematoma, tendinitis, osteoarthritis, sciatica, and cellulitis resemble
S/S:
Pain, tightness in calf
Possible swelling
Warmth, tightness of musculature
ST:
Homans sign-DF and hold, squeeze belly of calf and look for pain, knee is flexed
Tx:
Ultrasound to confirm
Ankle fx/dislocation
Forceful abduction, PF, IR, avulsion fx
inversion, eversion, or rotation:fib or malleolus
Calcaneal and talus fx will present as ankle sprain
Hugier or high dupuytren fx: fibular shaft-may still be able to walk
S/S: Swelling and pain Some or no deformity Snapping or crack noise Pain at site and can radiate Crepitus or discontunity with palpation Ecchymosis
St:
Squeeze
Tx: Splinting RICE Walking cast or brace NWB 7-9 wks
Osteochindritis dissecans
Single trauma or repetitive stress
Articular cartilage and underlying bone detached
Lateral ankle sprain can start as a chondral lesion that develops into this condition-pain deep in joint and along tibial portion of mortise
S/S:
Pain and effusion
Catching, locking, or giving way
Tx:
MRI to confirm
Immobilized and delayed WB
Surgery
Achilles’ tendon strain
Sudden excessive DF
Avulsion or rupturing if severe enough
S/S:
Acute pain and extreme weakness with PF
Tx:
RICE
Stretching and strengthening the heel cord
Lift should be placed in the heel of each shoe to decrease stretching of the tendon
Fibularis tendon subluxation/dislocation
Apply dynamic forces to the foot and ankle
Direct blow to the posterior lateral malleolus
Inversion sprain or forceful DF ankle can fear the fibularis retinaculum, allowing the tendon to dislocate outside the groove
S/S:
Tendons snap out of the groove with activity and then back in when stress is released
Eversion against resistance will replicate
Recurrent pain
Snapping
Ankle instability
Ecchymosis, edema, tenderness, and crepitus
Tx:
Compression with a felt pad cut in a horseshoe-shaped pattern that surrounds the lateral malleolus
Rigid plastic or plastic splint until acute signs have subsided
RICE, NSAIDS, analgesics
5-6 wks
Rehab-ROM, balance
Surgery
Anterior tibialis tendinitis
Downhill running
S/S:
Pt tender
Pain when tendon is stretched or when muscle is contracted
Tx: Rest and avoid hills Ice packs Stretching before and after running Strengthening program Oral anti inflammatory meds
Posterior tibialis tendinitis
Hyper mobility or pronated feet
Repetitive micro trauma occurring during pronation
S/S:
Pain and swelling in the area of medial malleolus
Edema and pt tenderness directly behind the medial malleolus
Intense during resistive inversion and PF
Tx: RICE, NSAIDS, and analgesics NWV short-leg cast with foot in inversion Correct pronation Low dye taping Orthotic device
Fibularis tendinitis
Pes cavus, excessive supination
S/S:
Pain behind the lateral malleolus when rising on the ball of the foot during jogging, turning, running, cutting activities
Tenderness over the tendon located at the lateral aspect of the calcareous distally beneath the cuboid bone
Tx: RICE and NSAIDS Taping with elastic tape Warm up and flexibility exercises Low dye taping or orthotics to support and prevent excessive supination
Skin contusion
No tissue there to protect the area
S/S:
Intense pain
Hematoma forms rapidly and tends to exhibit a jelly like consistency
Tx:
RICE, NSAIDS, analgesics
Compression, aspiration
Rehab-ROM
Doughnut pad under orthoplast shell for protection
Osteomyelitis-destruction and deterioration of bone
Muscle contusion
Being kicked in the back of the leg
S/S:
Pain, weakness, and partial loss of the use of the limb
Hard, rigid, and somewhat inflexible area because of internal hemorrhage and muscle guarding
Tx:
Stretch the muscles in the region immediately to prevent spasm and then to apply a compression wrap and ice go control internal hemorrhaging
Massage and whirlpool and ultrasound
Elastic wrap or tape support
Leg cramps and spasms
Fatigue, excess loss of fluid through sweating, and inadequate reciprocal muscle coordination
S/S:
Pain with contraction
Tx:
Relax to relieve the muscle cramp
Firm grasp of contracted muscle, with stretching relieves most acute spasms
Ice pack or gentle ice massage to reduce spasm
Gastroc strain
Quick starts and stops and jumping
Quick stop with the foot planted flat and suddenly extends the knee, placing stress on the medial head of the gastroc
Tennis leg-rupture or tear of the juncture of the gastroc and Achilles’ tendon
S/S:
Pain, swelling, and muscle disability
Hit in the calf with a stick
Edema, pt tender, functional strength loss
Tx: RICE, NSAIDS, analgesics Stretch after cooling WB as tolerated Heel wedge may reduce stretching of the calf muscle during walking Elastic wrap while active Gradual program of ROM
Acute leg fx
Direct or indirect trauma
Bony displacement with deformity that results in overriding of the bone end
Crepitus and a report loss of limb function
S/S: Soft tissue insult or hemorrhaging Severe pain and disability Hard and swollen Volkmanns contracture- result of internal tension caused by hemorrhage and swelling within closed fascism compartments, inhibits blood supply and results in muscle necrosis and contractures
Tx:
Fx reduction and cast immobilization-6 wks
Lateral ankle sprain
Decreased proprioception, decreased muscular strength, pes cavus, tightness of triceps surae (open-packed and PF already)
MOI: plantarflexion and inversion/supination while open packed-(ATFL and CFL) or dorsiflexion and supination while closed packed (PTFL usually associated with tears of above as well)
Grade 1: mild pain and disability, WB minimally impaired, pt tender and swelling over ligament w/no laxity. RICE, horseshoe pad, limit WB for 2 days, aggressive rehab w/ROM, strength, proprioception, talus jt mobs, taping, out 10 days
Grade 2: pop or snap, moderate pain and disability, tenderness and edema, positive false tilt, anterior drawer, RICE, Tallus mobs, crutches for 10 days, boot for 2 weeks, ROM, PNF, strength, proprioception, isometrics, 4 weeks, taping
Grade 3: tear of ATFL, CFL, PTFL, severe pain, NWB, swelling, discoloration, positive talar tilt and anterior drawer, RICE, cast or boot for 3-6 weeks, crutches, isometrics, ROM, proprioception, surgery may be necessary, can damage the peroneal nerve
S/S: Sensation of popping and MOI Localized pain along lateral ligament complex Rapid, Diffuse swelling Pt tenderness Painful inv, PF, and decreased ROM Medial ankle pain
ST:
Anterior drawer
Talar tilt
