Ankle and Foot Flashcards
define a low/lateral ankle sprain (LAS)
-“An acute traumatic injury as a result of excessive inversion of the rear foot or a combined plantar flexion and adduction of the foot”
what is the clinical presentation of low/ lateral ankle sprain
o Acute signs and symptoms eg. Heat, swelling, redness, pain
o most have supination injury mechanism (PF + inversion, with or without ADD/IR)
o some have pronation/eversion mechanism (DF,EV,ER and ABD) resulting from external force
o non-contact injuries caused by sub-optimal foot position at foot strike when running, landing or take off
o F>M
o Children>adolescents>adults
how do you diagnosis a LAS
o MOI?
o Palpation
o AROM and PROM of TCJ,STJ,mid-foot, fore-foot and 1st MTPJ, PF, DF, Inver, Ever
o Specific muscle tests such as Extensor hallucis longus, tibialis anterior, tibialis posterior, fib longus and brevis and flexor hallucis longus
o Knee to wall test
o Resisted isometric muscle tests
o Ligament stress tests such as Anterior drawer, and talar tilt (increased laxity)
how do you treat or manage a LAS
o Grade 1 and 2
SPRICEMM
POLICE
o Grade 3
The above plus CAM-walker,moon-boot
Surgery, reconstruction or ligament repair
o Important to manage the inflammatory response and pain
o Manage severe ankle sprains by immobilisation
o All ankle sprains – a limited period of joint protection with a graduated return to FWB is indicated (first 12-48 hours needs to be unloaded and protected)
How do you rehab a LAS
o Grade 1 and 2
SPRICEMM
POLICE
o Grade 3
The above plus CAM-walker,moon-boot
Surgery, reconstruction or ligament repair
o Important to manage the inflammatory response and pain
o Manage severe ankle sprains by immobilisation
o All ankle sprains – a limited period of joint protection with a graduated return to FWB is indicated (first 12-48 hours needs to be unloaded and protected)
What is a high ankle sprain (HAS)
inferior-tibiofibular joint/ syndesmotic sprain
What is the MOI for HAS
o Forced ER of the foot – damages syndesmosis and widens mortise, can also tear interosseous membrane and/or fracture proximal fib caused by powerful AB/ER forces to the forefoot
o hyper-DF – talus forcing malleoli apart, can rupture ATFL and PTFL, usually occurs when foot is planted and athlete falls or is pushed forward
o All Weber C #’s and 50% Weber B #
what are subjective features of HAS
o focal pain above ankle joint
o does not look too bad, minimal swelling and bruising sometimes
o poor tolerance of WBing
o LEVEL OF PAIN IS DISPROPORTIONATE TO SEVERITY
what are the objective/physical features of HAS
o NOTE: tests need to be done within the hour of injury or 4-7 days after
o No single test is sufficiently accurate for diagnosis so need to combine S+S and tests
o ‘Kleiger’s test’ (ER stress test)
o ‘syndesmosis squeeze test’
o ‘fibular translation test’ to diagnose
o Inability to hop
o +ve DF-ER stress test and squeeze test
o Syndesmosis TOP
how do you treat/manage HAS
G1: Tape to support syndesmosis joint, FWB
G2: boot immobilisation, NWB-FWB day 21, strapped for activity
G3: boot immobilisation, NWB-FWB 5 weeks, strapped for activity
what is a Lisfranc Ligament Injury
- Lisfranc ligament is between the big toe and second toe
- MOI – direct blow to the joint or by axial loading along the metatarsal with medial or lateral rotational force
what are the subjective features of chronic ankle instability (CAI)
3 main clinical features:
Mechanical instability
Perceived Instability
Recurrent sprain (episodes of giving way)
o Perceived instability is most consistent predictor of disability
what are the objective features of chronic ankle instability
+ve manual stress tests eg. Anterior drawer, posterior drawer and talar tilt
Impaired balance e.g star excursion test, side-side hop test, figure 8 hop test
how do you diagnosis a CAI
o No ankle effusion
o Full pain free ankle
Acute: Hip dominant landing strategy
Sub acute: changes persist, increase in hip stiffness and pre-landing inversion
Strategies change in both limbs
Increased postural sway in balance test
how do you treat CAI
o Prevent further episodes
o Teach optimal landing strategy
o Improve proprioception
o Taping and bracing can help short term but need to be used in conjunction with neuromuscular training
o Proprioceptive (NeurMusc) training programmes must have balance component
what is osteochondral talar dome lesions
injury or abnormality of the talar articular cartilage and adjacent bone
what are clinical features/diagnosis of osteochondral talar dome lesions
o MOI is either atypical sprain such as landing with compression or shearing force or associated with typical ankle sprain (PF, Add, Inver)
o Pain on WBing
o Poor tolerance of compression or loading
o Ache as rest
o Talocrural joint swelling
o Injury fails to resolve is a huge indicator of something more sinister
o Persistent swelling
o Scan assists diagnosis
what are physical features of osteochondral talar dome lesions
o Persistent effusion
o TOP of talar dome
o Altered joint mobility
o Compression and shearing tests provocative
what is post-traumatic synovitis
- Is a persistent and disabling synovitic reaction to trauma
What are the symptoms of post-traumatic synovitis
o Early symptoms: Same as acute ankle sprain o Later symptoms: Ankle fails to progress Persistent swelling and pain Overall slow recovery Loss of ROM TOP along joint line
what is an anterior and posterior impingement
o Is a secondary injury due to repetitive loading/collisions between articular margins and soft tissues
what are the clinical features of anterior and posterior instability
o Painful limitation of ROM
o Usually from post-trauma e.g ankle sprain, forced PF (ballet)= posterior; or forced DF (kicking a ball) = anterior
o Can have osteophyte formation due to repeated capsule-ligamentous traction of ankle joint
What is chronic ankle instability
both mechanical and functional instability of the ankle joint and
where symptoms of giving way” and instability have been
present for at least one year post-initial sprain injury
what is functional ankle instability
Reports of frequent episodes of “giving way” of the affected
ankle joint and feelings of instability during function (With/without actual mechanical instability)
what is the treatment/management for anterior and posterior instability
o Conservatively manage by de-loading it
o Possibly use a heel lift (anterior impingement)
o Address biomechanical and training issues
o Graded return to activity
o Cortisone injection can be used or surgical debridement
what is the sinus tarsi syndrome
- Sinus tarsi is an anatomical space bound by the talus and calcaneum
- It is inflammation of the sub-talar ligaments, synovium and fat pad within osseous canal
what are clinical features of sinus tarsi syndrome
o Report of anterolateral ankle joint pain
o Report rear foot instability during activity
o Swelling in front of lateral malleoli
oTOP over sinus tarsi
o Altered Rom of subtalar
o Pain on passive inversion and eversion
what is medial tibial stress syndrome
- MTSS is a non-inflammatory bone stress reaction caused by chronic repetitive loading that induces tibial bending forces. Bending occurs at narrowest point (middle to distal 1/3 of tibia) which is where MTSS occurs
What are clinical features of medial tibial stress syndrome
o Pain at attachment of posterior compartment muscles to tibia (esp. tib post)
o MOI is:
Intrinsic - excessive pronation, PF muscle tightness and running technique (overpronating)
Extrinsic – change in training surfaces, foot wear, TLERI?
Excessive or prolonged pronation can lead to eccentric loading of supinators.
what are stress fractures clinical features
o Gradual onset with deep, nagging pain with exercise and at rest afterwards
o TOP
o X-ray can help but only in later stages, bone scan with give +ve result
what are common sites of stress #
Femoral neck Pubic ramus Femoral shaft Tibia Navicular Metatarsal shaft
what are subjective features of stress #’s
-Look at notes (pg 92 in peri musc notes workbook)
what is compartment syndrome
- Pressure related pain secondary to increased compartment pressure during exercise
- May be to do with inadequate vascular outflow which impedes oxygenation of muscle and neural tissue
- Activity dependent
what are the 3 compartments that can be affected in compartment syndrome
o Anterior – deep fibular nerve (common)
o Posterior – superficial fibular nerve
o Deep posterior – tibial nerve (common)
what is the clinical presentation of compartment syndrome
o Gradual onset of pressure pain in the affected compartment
o Feeling of tightness and fullness in the affected compartment
o Mechanically patterned – it is worse after a predictable duration of exercise
o Relieved with rest
o TOP
treatment of compartment syndrome
o Poor response to conservative treatment
o Surgery commonly required
Look at notes–> pg 93
what is plantar fasciosis
- Is a non-inflammatory stress reaction of the plantar aponeurosis at the medial calcaneal tubercle
- Behaves like an overuse tendinopathy
what are the sujective features of plantar fasciosis
Gradual onset of burning pain in proximal aspect of medial, longitudinal arch
Common in running athletes or sedentary people with unaccustomed loading
Behaves like a tendinopathy e.g AM/post-rest stiffness and pain upon WBing, symptoms may ease with activity
Aggravated by WBing that load plantarfascia
Night/rest pain, can be associated with calcaneal oedema
Can develop acutely partial tears not uncommon
what are physical features of plantar faciosis
Avoid loading through 1st MTPJ with heel raises
Pain on DF/SL heel raise when loading the 1st MTPJ
Loss of 1st MTPJ extension – usually due to decreased plantar flexion length
Local, mild swelling
Acute tear may have inflammatory symptoms
TOP – medial calcaneal tubercle especially
Local thickening, texture change and crepitus
MOI of ligaments
LOOK AT NOTES
what is the bifurcate ligament
lateral calcaneonavicular ligament and anterior calcaneocuboid ligament
how is the bifurcate ligament injured
injured by strong inversion producing an avulsion fracture at the calcaneus
Disgnosis/management for bifurcate ligament injury
- TOP and PF/SUP
- get MRI or x-ray
- immobilise for 4 weeks
where is the lateral calcaneocuboid ligament and its MOI
- under the anterior C-C ligament
- injured by typical sprain mechanism
diagnosis and treatment for lateral calcaneocuboid ligament
- TOP and inversion
- Can send for x-ray/MRI
- treat like a typical ankle sprain
What is a weber A #
Fracture of the fibula distal to syndesmosis. An oblique medial malleolus fracture may also be present
what ligaments can be injured with weber A #
occur with a sprain of the lateral ligaments. ATFL, CFL and PTFL would all be implicated due to their proximal attachments being around the lateral malleolus
what is a weber B#
Fracture of the fibula at the level of the syndesmosis.
what ligaments can be injured with weber B#
occur with sprain of the medial ligaments. Deltoid ligaments would be implicated as they all proximally attach on the medial malleolus
what is a weber C#
Fracture of the fibula proximal to syndesmosis. .
what ligaments can be injured with weber C#
occur with syndesmotic injury so syndesmosis is implicated but also deltoid ligaments due to widening of mortise and associated medial malleoli fracture
what are the ottawa ankle rules
-An ankle XR is required if any of the following are evident:
oTenderness or pain at:
Posterior edge of tibia (6cm) or tip of medial malleolus – important for Weber #’s
Posterior edge of fibula (6cm) or tip of lateral malleolus – important for Weber #’s
Base of 5th metatarsal - important for avulsion fracture
Navicular
oUnable to WB at time of the injury - indicative of serious pathology esp if associated with huge inflammatory response
oUnable to walk 4 steps in clinic or ED - indicative of serious pathology esp if associated with huge inflammatory response
what are key subjective features following traumatic injury to ankle and foot
- precise location of pain
- MOI
- Audibe cracking/popping–> may indicate #
- ability to WB after injury imediately–> if can’t then srs injury
- location, degree and severity of swelling
- delayed/optimal/inadequate inital management
- prior Hx of similar injury
what are the common complications of acute ankle ligament injury
- CAI/FAI
- Talar dome #
- post traumatic synovitis
- ankle impingment
- oedema–> figure 8 method of palpation = navicular tuberosity, distal tip of lateral maleolus, distal tip of medial maleolus, base of 5th metatarsal
- # ’s
what is the reliability, sensitivity and specificity of foot and ankle disability index (FADI)
o Not good for diagnosis
o Shows changes in activity limitations, participation restrictions and disability over time
o FADI Sport – is sport sensitive to deficits associated with CAI and better at picking up Fx deficits so better for higher functioning patients
what is the reliability, sensitivity and specificity of identification of functional ankle instability (idFAI)
o Useful to determine risk of developing FAI
o Better able to diagnose FAI
what is the reliability, sensitivity and specificity of foot and ankle ability measure (FAAM)
o Often used with FADI
o Both have an ADL and a sport sub-scale
o Can distinguish between a healthy athlete and one with CAI – not sure if its sensitive enough or specific enough to diagnose though
what some intrinsic factors that may lead to development of tissue injury
o Physiological make up e.g pronated foot, supinated foot, high arches
o Gender – F>M get LAS, Males may be at more risk of traumatic injury due to high impact sports
o Bone density
o Muscle mass – compresses other tissues
o Circulation – causes compartment syndrome if tissues not vascularised properly
what some extrinsic factors that may lead to development of tissue injury
o Training load – an increase in training load too soon increases risk of injury
o Environment – indoor sports have more ankle sprains
o Foot wear – ill-fitting shoes can cause overuse injuries
o Equipment – a bike that is ill fitting can cause an overuse of the achilles maybe?
