Ankle and Foot Injuries in Sports Medicine Flashcards
what are stress fractures
-partial or complete fx of bone due to its inability to withstand repetitive non-violent force
95% of stress fractures occur where
in the LE
stress fractures account for what % of running injuries
10%
where are stress fracture most common
foot and ankle
when does a stress fracture occur
- when the bones ability to repair itself is outpaced by continued repetitive forces
- often occurs in activities that involve muscle fatigue
what happens what muscle fatigues
- it loses its ability to contract and redistribute the energy along the course of the muscle
- the bone must then take on the higher undistributed load
what will tension force proceed into
to a symptomatic stress fx and eventaully a complete fx
how do compression fractures occur and do they result in a complete fx
- occur slowly
- do not go on to a complete fx (tension fracture occur more rapidly)
a higher incidence of stress fx occur in who
- women with amenorrhea
- assocaited with low levels of estrogen
women incur more —stress fx
bilateral
stress fractures are largely correlated with what
- fitness and level of activity
- age and fitness
are age and gender correlate to stress fracture
no
what factors are involved in stress fx
- shoe mileage (look for creases, wobble and wear in mid sole of shoe)
- LLD (50/50 which side injury is on, depends on compensation)
- changes in running surface
- gait variations
what are the signs and symptoms of a stress fracture
- tenderness over area
- pain upon weight bearing
- reproduce pain with inciting activity
- may see slight edema (may not see edema)
what diagnostic tools are used dx a stress fx
- x-ray (14 day rule)
- bone scan
- C.T
- tuning fork (50% false negative) and ultrasound
what structures are at risk of stress fx
- navicular, proximal second MT
- any intra-articular structure in the foot and ankle
what structures are less critical stress fx
- medial malleolus
- proximal 5th MT
- talus
what structures are noncritical stress fx
- distal MT (very common)
- lateral malleolus
- calcaneus
how do you treat stress fx
- decreases activity - let the pain be your guide
- change activity - circuit training, exercise machines, swimming
- change foot wear
- orthoses
- immobilization when indicated
what are shin splints
garbage term describing overuse injuries involving the lower leg
what is enthesitis
inflammation of the insertion of the tenon into the bone
what is periostitis
covering of bone that has all the nerve and vascular structures involved
what is myositis
inflammation of muscle
what is tenonitis
inflammation of tendon
what are the causes of posterior medial shin splints
- overuse of posterior tibialis m
- usually due to increased velocity (acceleration) of pronation
- eccentric contraction after heel strike (this is when the moments around the STJ are highest)
what are the most common shin splints
-anterior lateral shin splints
anterior-lateral shin splits are due to
- overuse of TA muscle
- increased velocity (acceleration) of ankle joint plantarflexion; also associated with STJ pronation
- eccentric contraction at heel contact when the ankle joint moments are highest
what factors are involved in shin splints
- shoes
- running surface
- tight opposing muscle groups
- weak muscle groups
- running variations
- foot morphology
what are signs and symptoms of shin splints
- diffuse pain that starts out late in a workout
- as it gets worse it becomes more localized earlier in the workout
- usually not tender on weight bearing (unlike stress fx)
- often can palpate the area of tenderness (b/c of inflammation)
- activities such as running in place can elicit discomfort
how do you diagnose shin splints
- primarily a clinical diagnosis
- x-ray
- bone scan
what is the treatment for shin splints
- decreased activity
- substitue activity
- orthoses and shoes
- stretch and strengthen
- physical therapy
chronic compartment syndrome (CCS) is difficult to distinguish from what
shin splints
it is important to differentiate CCS from what
acute compartment syndrome - medical emergency
CCS is caused by what
- high pressure in the fascial boundaries causing ischemia
- increased pressure comes from increased muscle volume and intra and extracellular fluid accumulation during activity
- increased pressure may then lead to venous and lymphatic compromise which will worsen the situation
- nerve compromise
what are the signs and symptoms of CCS
- pain after a certain distance, time or intensity
- dull, achy, stabbing pain along the lower limb
- may have a perceived muscle tightness or fullness
- eventually will see neurological symptoms (parasthesias in toes/muscle belly)
in CCS when does the pain subside
- after activity
- the longer the activity the longer it will take for the pain to subside
what compartments are most affected in CCS
-anterior and deep posterior compartment
1 in 5 patients with CCS have a hx of
stress fracture
how do you perform a PE for CCS
first have your patient exercise (ie. treadmill)
what is found during a PE for CCS
- pain to palpation along the compartment (compress muscle)
- decreased neurological sensation and parasthesias
- herniations occur in 20-60%
how do you dx for CCS
-radiology
-compartmental pressure:
preexisting pressure = 15mmHg
1 min post exercise pressure >/= to 30 mmHg
5-10 min post exercise = 15mmHg
how do you treat CCS
- decreased activity
- substitute activity
- orthoses and shoes
- PT
- surgical decompression
up to 18% of runners will exhibit sings of what
achilles tendonitis
what is insertional achilles tendonitis
- involves the tendon/bone interface
- often associated with a haglund’ deformity
what is non-insertional achilles tendonitis
-proximal to the insertion
what factors are involved in achilles tendonitis
- excess mileage
- improper training techniques
- inadequate shoes
- tight posterior muscle group
- excessive pronation
often you do not see pts with achilles tendonitis until
there is a partial or complete tear
non-insertional achilles tendonitis occur in who
- usually middle aged weekend athletes
- male»_space;female
where do non-insertional achilles tendonitis involve avascular zone
2-6cm proximal to the insertion
in non-insertional achilles tendonitis when is pain the worse
in the A.M and with activity but many do not have symptoms prior to rupture
what will you see on a non insertional achilles tendonitis when you squeeze the calf muscle
a depression
what will be seen on PE for a non-insertional achilles tendonitis
- localized tenderness and crepitus
- palpable “knot”
- x-ray may show calcification
- tenograms and MRs are best
what tools are used to diagnose an achilles tendon rupture
tenogram or MR is best
insertional tendonitis is caused by
overuse enthesopathy
insertional tendonitis is often associated with what
retrocalcaneal bursitis
chronic inflammation of an insertional tendonitis results in
calcification
medial insertional tendonitis is seen with what
over pronation (midstance)
what will be seen during PE for insertional achilles tendonitis
- erythema and edema
- pain to palpation at insertion
- worse after exercise
- palpable mass posterior lateral calcaneus
- x-ray show some degree of haglund’s deformity and possible spur
how do you treat Achilles tendonitis
(Binnell surgery primary repair) 1/8” heel lift or medial heel wedge Achilles Tendonitis Walking Boot Orthoses and new shoes Stretching in non-acute cases Ultrasound
how do you prevent Achilles tendonitis
-warm-up and stretching in the prevention of muscular injury
posterior tibial tendonitis is linked with what
excessive pronation
PTT occur most frequently in males or females
females
what clinical signs are evident with PTT
Clinically may have crepitation with motion
Pain with active and passive eversion motion
Pain against inversion resistance
Pain against inversion resistance
Pain with heel raises (or marked weakness)
No Calcaneal inversion with heel raises
when do you often see peroneal tendonitis
after periods of inactivity followed by intensive workout schedule
where does peroneal brevis tendonitis produce pain
at the base of the 5th MT
both peroneal brevis and longus can produce pain where
posterior to the lateral malleolus
extensor tendonitis is often seen in
skating and skiing due to tight boots
in extensor tendonitis what does the ankle joint exhibit
rapid plantarflexion and a “foot slap” may be heard
how do you treat extensor tendonitis
Modification of activity Substitution of activities Stretch and strengthen Ultrasound / phonophoresis Soft to ridged orthoses therapy
ankle sprains are due to
- plantarflexion/inversion
- dorsiflexion
- eversion deltoid lig.
what are the grades of ankle sprains
1st degree
2nd degree
3rd degree
what is 3rd degree ankle strain
- unstable
- repair if you can’t get congruity or fails to align
- BK cast
what is the squeeze test
-compress mid calf - test tib/fib syndesmosis
what is a 2nd degree ankle sprain
- stable
- functional impairment
- some joint laxity
- splint and rehabilitation indicated
what is the Ottawa Ankle Rule***
films are required if:
- Pain at malleolar area, navicular, styloid process – avulsion fx
- Bony tenderness
- Inability to bear weight
when are arthography used to diagnose ankle sprains
- used for acute dx (24-48 hrs)
- few false (+)
- disruption unlikely if there is no leakage
arthrography of ankle sprains
Superior anterior lateral = ATFL
Peroneal sheath = ATFL + CFL
Posterior = syndesmotic tear
how do you treat subacute lateral ankle instability
-Subacute phase (3 days – 3 weeks) Goals = mobility, contractures, strength, proprioception Contrast baths and cryotherapy as indicated Air cast Partial to full WB activities Exercise Alphabet, therabands, BAPS board Achilles and peroneals (overlooked)
how do you treat reparative phase lateral ankle instability
-Repairative phase (3 weeks to 3 months)
Goals = full function and return to sport
Spot icing
Brace, tape, orthoses
Gradual return to activity
(osteochondritis dessicans or bone chip restricts joint ROM)
(Ankle fx is rare in sports med compared to ligamentous injury)
what is turf toe
- sprain of the 1st MTPJ
- commonly injured while wearing flexible shoes on a surface such as artificial turf
how do you treat an acute phase of lateral ankle instability
-Acute phase (0-3 days) Goal = edema, pain, spasm Cryotherapy - ice Compression Elevation Exercise (NWB) – spell alphabet out with toes Isometric exercises Achilles stretch
how do you treat subacute lateral ankle instability
-Subacute phase (3 days – 3 weeks) Goals = mobility, contractures, strength, proprioception Contrast baths and cryotherapy as indicated Air cast Partial to full WB activities Exercise Alphabet, therabands, BAPS board Achilles and peroneals (overlooked)
how do you treat reparative phase lateral ankle instability
-Repairative phase (3 weeks to 3 months)
Goals = full function and return to sport
Spot icing
Brace, tape, orthoses
Gradual return to activity
(osteochondritis dessicans or bone chip restricts joint ROM)
(Ankle fx is rare in sports med compared to ligamentous injury)
turf toe is usually caused by what
- hyperextension force
- if problem persists or worsen, surgery may be required
how do you treat turf toe syndrome
Protect Rest Ice Compression Elevate Avoid wt bearing 2-4d Recovery (3-4 wks) orthoses
