Ankle and Foot Flashcards
What is the order from most common to most rare ankle sprains?
-Lateral
-Medial (5-10%)
-High (syndesmotic)
When are ankles the least stable, therefore most vulnerable to sprain?
In loose packed position of plantarflexion with inversion
What sprains are commonly misdiagnosed as high ankle sprains?
Grade II and III lateral ankle sprains
What is the recovery time of a grade I lateral ankle sprain?
2-10 days
What is the recovery time of a grade II lateral ankle sprain?
10-30 days
What is the timeframe for recovery of a grade III lateral ankle sprain?
30-90 days
What often comes with a grade III lateral ankle sprain?
Fracture
What are the tests for a lateral ankle sprain?
-Anterior Drawer
-Talar Tilt
What are some common sequelae with a lateral ankle sprain?
-Superficial peroneal/fibular nerve involvement
-Base of the 5th metatarsal
-Spiral fracture of the fibula
-Lateral malleoli fracture
-Navicular
What are the ottawa ankle rules?
-TTP at either malleoli, navicular, base of 5th metatarsal
-Inability to weight bear immediately and in emergency department (doesn’t have to be pretty, 2-3 steps)
What are signs of a medial/eversion ankle sprain?
-Localized pain over the deltoid
-Positive eversion talar tilt test
What are the mechanisms of injury for a high ankle sprain?
-Hyper-dorsiflexion
-Rotation and plantarflexion
How long is recovery from a high ankle sprain?
> 6 months
What are special tests for a high ankle sprain?
-syndesmotic squeeze
-ER stress test
-Fibular translation test
When to get off of the crutches?
When able to walk well
What is acute management of ankle sprain?
-RICE
-Crutches (reduce, don’t eliminate weightbearing)
-Early mobilization
-Maybe immobilize
When is a boot indicated for lateral ankle sprain?
Grade III
Why manual therapy with ankle sprains?
Improves pain and function
Why exercise therapy with ankle sprains?
Reduces risk of recurrent ankle sprains and functional instability
What to incorporate with neuromuscular reeducation with ankle sprains?
-SL Balance
-Unstable surfaces
-Dynamic movements
What are the two components of chronic ankle instability?
Mechanical instability (impaired arthrokinematics and joint degenerative changes)
Functional instability (altered neuromuscular control, strength deficits)
What have no effect in the treatment of acute ankle injuries?
Ultrasound
Laser therapy
Electrotherapy
What type of brace is recommended for return to sports after ankle sprain?
Lace-up or semi-rigid
What are the goals for closed chain dorsiflexion of the ankle?
38 degrees or 9-10 cm from wall
What are red flag/risk factors for malignancy?
-Constant pain not affected by position or activity
-Age over 50
-History of Cancer
-Failure of conservative intervention
-Unexplained weight loss (10% of person’s body weight without trying to lose weight)
-No relief with bed-rest
What cancers are most likely to matastasize to the spine?
-Prostate
-Breast
-Kidney
-Thyroid
-Lung
What is the description of diabetic neuropathy?
Aching and numbness of feet and distal lower extremity
-Burning, prickling, tingling, extreme sensitivity
-most often bilateral, can be unilateral
-Aggs/eases correlated with glucose
What are some vascular conditions to be aware of?
-Venous thromboembolism
-Intermittent claudication from peripheral arterial disease or iliac artery obstructive disease
When are venous thromboembolisms most often seen?
In patients with:
-cancer
-following surgery
-trauma
-prolonged immobilization
Which area of the leg are considered more dangerous to have venous thromboembolisms?
Proximal to the bifurcation of the popliteal vein
What is the Well’s Criteria for venous thromboembolism?
-Active cancer within 6 mos +1
-Paralysis, paresis, or recent immobilization +1
-Recently bedridden >3 days or major surgery within 4 weeks +1
-Localized tenderness along deep venous system +1
-Entire lower-extremity swelling +1
-Calf sweling by >3 cm compared with other extremity +1
-Pitting edema
-Collateral Superficial veins +1
-Alternative diagnosis as likely or greater than that of DVT -2
What conditions are correlated with peripheral arterial disease?
-Coronary artery disease
-Cerebrovascular disease
How common is peripheral arterial disease in individuals over 70 y/o?
20% incidence; more with advancing age
What characteristics are consistent with peripheral arterial disease?
-Cramping
-Tightness
-Tiredness
-Aching
-Relieved with rest
What is highly diagnostic of peripheral arterial disease?
Palpation of the posterior tibial and dorsalis pedis pulses
What are risk factors for peripheral arterial disease?
-Smoking
-Diabetes
-Hypertension
-Hypercholesterolemia
-Hyperhomocysteinemia
-C-reactive protein
(Hyperhomocysteinemia- high levels of homocysteine;
C-reactive protein - increases when there is inflammation in the body)
What is c-reactive protein?
A protein created by the liver that rises in response to inflammation in the body.
What factors are important to look for with risk pf peripheral arterial disease?
-Age (1 point for every 5 years 60 and above)
-Smoking (2 if ever smoked, 7 if current)
-Hypertension (1 for treated hypertension, 3 for not treated hypertension)
How many points on the clinical prediction model for peripheral arterial disease warrants an
ABI?
7
What is a normal ABI?
1.0-1.3
What ABI is diagnostic for peripheral arterial disease?
<0.90
Severe is less than 0.4
What is the ABI?
Lower extremity systolic pressure/brachial artery systolic pressure
Where is pain from iliac artery occlusive disease?
-Buttocks
-Thigh
What is leriche syndrome?
-Decreased femoral pulses
-Muscle Atrophy (including thigh)
-Impotence
What areas are most commonly painful with Hip OA?
-Anterior groin (66%)
-Gluteal (71%)
-Anterior thigh (27%)
-Posterior thigh (24%)
-Anterior knee
-Posterior knee
-Anterior shin
-Calf
What is the CPG for hip OA?
-Hip Pain
-Hip IR <15 degrees
-Pain with hip IR
-Matutinal stiffness <60 minutes
-Age >50 years
What is the cluster for knee OA with knee pain?
-Age >50 years
-Morning stiffness <30 minutes
-Crepitus
-Bony tenderness
-Bony enlargement
-No palpable warmth
What are some characteristics of imaging and lumbar spinal stenosis?
-Significant evidence in asymptomatic individuals
-No consistent relationship between image findings and results of treatment
What are indications of lumbar spinal stenosis?
-Age>50
-Insidious onset of chronic, progressive low back pain, and more recent lower extremity symptoms
-Lumbar spine movement restrictions
-Intolerance of extension
-Preference of flexion
What are included in the cluster for lumbar spinal stenosis?
-No pain while sitting
-Pain below buttock
-Age >65
-No pain with flexion
-Sitting best posture
-Standing or walking as worst posture
What are predictor variables of lumbar spinal stenosis?
-Bilateral symptoms
-Leg pain more than back pain
-Pain during walking/standing
-Pain relief upon sitting
-Age >48 years
What is the two stage treadmill test?
A test for lumbar spinal stenosis consisting of walking up to 10 minutes on a level treadmill, a treadmill inclined 15 degrees (both without using hands), and a recovery period. The time to symptoms on the treadmill are compared to the time needed to recover. Positive with:
-Longer time walking on incline (decreased time on level)
-prolonged recovery time after level walking
What is the bicycle test of van Gelderen?
Pedal in an upright posture until the onset of symptoms and then lean forward. If the symptoms abate, they have lumbar spinal stenosis.
What are the differences between relieving factors of neurogenic claudication vs. vascular claudication?
Neurogenic claudication eases with sitting, bending forward, squatting posture, vascular eases with rest
What are the differences between aggravating factors of neurogenic claudication vs. vascular claudication?
Neurogenic claudication aggs with standing, upright posture; vascular aggs with any leg exercise
Where is it pragmatic to provide thrust and non-thrust mobilization to individuals with lumbar stenosis?
-Thoracic
-Lumbar
-Pelvis
-Hip
-Knee
-Ankle
What is the comprehensive treatment approach for lumbar spinal stenosis?
-Flexion-based exercise
-Gluteal strengthening
-Targeted stretching (psoas, rectus femoris)
-Progressive aerobic exercise
What kind of walking program may be more helpful for individuals with lumbar spinal stenosis?
Inclined treadmill walking due to flexion
What is the benefit of exercise with intermittent claudication?
-Improved maximal walking time
(compared with angioplasty and surgical treatment)
(Angioplasty - using a balloon to open a narrowed or blocked artery)
What is the exercise program for individuals with peripheral arterial disease?
-at least 3x/week
-At least 30 minutes
-walking to near-maximal pain
-For at least 6 months
What are the Ottawa Knee Rules?
-Age > 55
-Isolated tenderness of the patella
-Tenderness at the fibular head
-Inability to flex to 90
-Inability to bear weight both immediately and in the ER (4 steps)
Are the Ottawa knee rules sensitive or specific?
Sn 100%, Sp 49%
With a fall or blunt-trauma, what are the factors to decide for knee imaging?
-Age <12
-Age >50
-Inability to walk 4 weight-bearing steps in ER
What is the difference in the ability to walk with the Pittsburg Decision Rule vs. Ottawa Knee rule?
PDR: full weight bearing
OKR: any amount of weight bearing
What is the most common stress fracture location?
Tibia
What are risk factors for tibial stress fracture?
-Women>men
-Military
-Runners >25 miles per week
-Walking
-Jumping
-Dancing
-Female athlete triad
What are exam findings with tibial stress fracture?
-TTP to anterior aspect of the tibia
-Edema
-Pos tuning fork test
Can tuning forks rule in/out stress fractures?
No, not confidently
What is management for tibial stress fracture?
-Activity reduction
What is used to diagnose tibial stress fractures?
MRI; also radiography or bone scan
What are the Ottawa ankle rules?
-TTP at distal 6 cm of tibia/medial malleolus
-TTP at distal 6 cm of fibula/ lateral malleolus
-Inability to bear weight both immediately and in the ED for 4 steps
What are the foot ottawa rules?
-TTP at base of 5th, navicular bone
-Inability to bear weight immediately and in the ED for 4 steps
What are the history and exam findings for avulsion fractures?
Violent muscle contraction resulting in hearing/feelin a “pop” noted by painful passive stretch or active contraction of involved muscle with pain on palpation
