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Clinic > Ankle > Flashcards

Ankle Flashcards

1
Q

Joints of the ankle

A

talocrural
inferior tibiofibular
Subtalar

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2
Q

Talocrural JT

A

• Articulation between the talus, medial malleolus (distal tibia) and lateral malleolus (distal fibula)
– 1° Weight-bearing synovial joint • Designed for stability
– Uniaxial modified hinge joint
• Flexion (plantarflexion)/extension
(dorsiflexion)
• Combined movements of inversion/eversion possible with subtalar joint

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3
Q

Inferior tibiofibular joint

A 
• Articulation between the distal tibia and the distal fibula
– Syndesmosis
• Designed for stability
– Slight “give” during dorsiflexion
• High ankle sprains
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4
Q

the subtalar joint

A

• Articulation between the talus and the calcaneus
– Plane synovial joint
• Pronation accompanied by calcaneal eversion (calcaneovalgus)
• Supination accompanied by calcaneal inversion (calcaneovarus)

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5
Q

lateral ligaments

A

ATFL
CFL
PTFL

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6
Q

Medial ligs

A

deltoid ligament

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7
Q

PE

A

• Observation
– Consider relevance of alignment inc. medial/ lateral/ transverse arches of the foot
• Baseline functional test – can you replicate the primary complaint?
– E.g.Walking,running,hopping,SKB

• Active Movement
– Rangeofmovement(ROM);quantity,andquality(andwhatlimits,e.g. pain, caution etc)
• Passive Movement
– Rangeofmovement(ROM);quantity,andquality(andwhatlimits
(End feel), e.g. pain, caution etc)
• Resisted tests
– Isometric,Isotonic,Functional;painandweakness

•
Palpation/Special tests/neurological assessment
– Specifictopathology/clinicalreasoning,and/orclearingtests?
• ‘Special’ orthopaedic tests
– Anteriordrawertest
– Talartilt
– Klieger’stest/externalrotationtest – Squeezetest(Thompson’stest)
– Compressiontest
• Any indication for vascular testing, e.g. skin colour changes, temperature changes
• Femoral pulse
• Popliteal pulse
• Posterior tibial pulse • Dorsalis pedis pulse

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8
Q

OTTAWA Ankle Rules

A

bony tenderness on medial/lateral malleolus 6cm up
Navicular
base of the 5th metatarsal
inability to weight bear both immediately and in the ED

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9
Q

Lateral ankle sprain

A

•Most common ankle injury (Nuhmani and Khan, J Musculoskelet Res 2013, 16(4)).
• One study showed that 70% of their
basketball players had a history ankle
sprain and 80% of them had multiple
sprains (Smith and Reischl, Am J Sports Med 1986 14 p 465)
– Jumping sports
– Running/cutting sports

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10
Q

lateral ankle sprain clinical presentation

A 
• MOI: Excessive supination/inversion (± plantarflexion)
– ATFL is the first to rupture (Nuhmani and Khan, J Musculoskelet Res 2013, 16(4))
• Signs and symptoms – pain+
– swelling/±Ecchymosis – instability
– WB or NWB?
• Differential Diagnosis
– Syndesmosis sprain
– Fractures
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11
Q

Lateral ankle sprain - diagnosis

A

• Patient History – MOI
• Palpation
• Ottawa ankle rules – X-ray • Special tests
• Outcome Measures
– Lower Extremity Functional Scale (LEFS) – Foot and Ankle Disability Index
– LLTQ

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12
Q

Lateral ankle sprain - mgmt

A

• Acute Phase (24 – 72 hours) – POLICE –
•OL Depend on grade of injury – Ankle pumps 10 – 20/hour
– Active and passive soft tissue techniques
– Transverse friction to improve healing – caution on the grad of injury.
(Walker J Orthop Sports Phys Ther 1984 6(2) p 89)
– Crutches (gait retraining) - WBAT
– Ottawa Ankle Rules (Imaging)
– Depending on severity (hydrotherapy)
– Taping/bracing
(Nuhmani and Khan, J Musculoskelet Res 2013, 16(4))

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13
Q

Lateral ankle sprain mgmt reparative phase

A

– Joint mobilizations
– Passive stretch (gastroc/soleus)
– Isometric exercise (as soon as the patient can tolerate) – Strengthening (peroneii, TA, extensors, triceps surae) – Proprioception (standing and sitting)
– Shoe assessment – Taping/bracing

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14
Q

lateral ankle sprain - mgmt remodelling phase

A

• Remodeling Phase (15 – 28 days, 3 weeks 60% strength, 3 months 100% strength)
– Begin running/jumping forward and backwards – Incorporation of multidirectional agility drills
– Progress to jumping sideways (over a line)
– Progress to box drills
– Incorporate multidirectional sports-specific proprioceptive exercises
– Simulated sport-specific exercises

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15
Q

Chronic ankle instability prevalence

A

• Estimated that 30% of people will develop CAI after initial sprain (Itay et al.
Orthopaedic Review 11(5), p73) • Mechanical (MAI)
– laxity of a joint due to loss of mechanical restraint (ligamentous)
• Functional (FAI).
– perception/realisation that the ankle gives
way, is weaker, more painful

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16
Q

CAI - clinical presentation

A 
• Recurrent ankle sprains • Giving way
• Altered activity level
Outcome Measures:
– Cumberland Ankle Instability Tool
– Ankle Instability Instrument
– Identification of Functional Ankle Instability Questionnaire
– Foot and Ankle Disability Index
– FootPostureIndex(FPI)
17
Q

CAI clinical Dx

A

• Patient history (recurrent ankle sprain)
•Special tests (ligament laxity/rupture)
• Altered neuromuscular control – impaired balance (SEBT, TTS)
– Impaired proprioception
– Impaired strength
– Slower firing of peroneal muscles (?) – Single Leg Stance
– Proprioception testing/balance
• SEBT, TTS
• Imaging (x-ray, MRI)

18
Q

CAI mgmt

A 
• Physical Therapy
• Strength
• Neuromuscular control
– EMG biofeedback
– US – as feedback (diagnostic)
• Proprioception/balance
• Ankle supports/braces
 • Foot orthoses (poor evidence)
– Increasing strength
– Improving joint position sense
– Improving functional test
• Single leg hoping
• Single and triple hop for distance • 6m and 6m crossed hop for time
19
Q

Causes of posterior ankle pain

A 
achilles tendinopathy 
achilles rupture 
retrocalcaneal bursitis 
posterior impingement syndrome 
Sever's disease
Achilles bursitis 
referred pain 
inflammatory entheseopathies
20
Q

AT - prevalence

A

• Incidence of 1.9 / 1,000 registered patients (GP clinic)
– Associated with physical activity (Maffulli et al., JRSM 97(10) p472)
– 58 cases 1⁄3 of patients did not participate in sport (Rolf and Movin
Foot Ankle Int. 1997 18(9) p565)

21
Q

AT clinical presentation / Dx

A 
• Signs and Symptoms
 – Typically 2° Overuse &/or change in activity level/type
– Pain
– Activity related pain
– Tendon thickening
– Pain on palpation
– Reduced strength (Pain)
– Stiffness of the tendon
– Imaging – Ultrasound
– Outcome Measure: VISA-A
22
Q

AT - mgmt/evidence

A

• Systematic Review on different protocols – Alfredson Exercise Protocol (Eccentric exercises)
• 3 sets x 15 reps twice daily, both w knee bent and straight
• heterogeneity of other studies limits other exercise protocols
– modified activity
– advice and education
– corticosteroid injection
• Evidence for short term relief (4/52) but with long-term
complications (6&12/12) (Coombes et al., 2010 Lancet 376(9754) p1751)
• 63% recurrence (Bisset et al., BMJ 2006, 33 p939)

23
Q

Therapeutic tendon loading exercises

A

• Exercise prescribed to ‘load’ the tendon
– Gravity alone or in tandem with weights, e.g. hand-weight, body-weight or resistive exercise band etc
• Popularised by Alfredson et al in the ‘90’s in relation to Achilles tendinopathy
– 15 recreational athletes with Achilles pain who had failed previous conservative care. Responded to a programme of heavy-load eccentric calf muscle training (Alfredson et al, 1998. Am J Sports Med 26: 360)
• Initially thought to stimulate remodelling of the tendon
• Now one of the most common conservative interventions for tendinopathy related pain

• Applied across the range of tendinopathies:
– Rotator cuff tendinopathy (e.g. Littlewood et al 2012, 2013)
– Elbow extensor tendinopathy (e.g. Croisier et al 2007)
– Patellar tendinopathy (e.g. Young et al 2005 )
– Achilles tendinopathy (e.g. Norregaard et al 2007 )
• But:
– TTLE is not a ‘one-size fits all approach’
• Some patients seem to benefit and others do not
– The patho-aetiology of tendinopathy remains poorly understood
– The mechanism of action of TTLE remains poorly understood
• See Drew et al., BJSM 2014, 48(12) p966; Allison and Purdam, BJSM 2009 43(4) p276 for more information

24
Q

talus

A 
•  Irregular shape
–  Movement controlled by bony
 ar/cula/ons
•  Posterior ar/cula/on with sustentaculum tali of calcaneus
•  Body, head and neck
–  Head and neck palpable
–  Head – navicular ar/cula/on
–  Neck
•  Medially /b ant & /b post
•  Laterally – sinus tarsi
•  Sinus tarsi
–  Neck and ATFL palpable –  TOP indicates??
25
Q

calcaneus

A

• Largest tarsal
• Sustains large impact forces
• Provides moment arm for achilles tendon
• Transmits BW from hindfoot to midfoot
• Posterior por/on
– DistalaspectonlygroundcontactinWB
– Plantarcalcanealtuberosity–aWachmentforintrinsicandplantaraponeurosis

Clinic (17 decks)

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