Ankle, AT & foot pain CPG

Question 1

Grade I

Answer 1

• no loss of function
• no ligamentous laxity (- anterior drawer / talar tilt tests)
• little or no hemorrhaging,
• no point tenderness
• decreased total ankle motion of 5° or less
• swelling of 0.5 cm or less.

Question 2

Grade II

Answer 2

• some loss of function
• • anterior drawer test (ATFL)
• • talar tilt test (no CFL)
• hemorrhaging
• point tenderness
• decreased total ankle motion > 5° ,<10°,
• swelling greater >0.5 cm <2.0 cm.

Question 3

Grade III

Answer 3

• near total loss of function
• • anterior drawer / talar tilt tests
• hemorrhaging
• extreme point tenderness
• decreased total ankle motion > 10°
• swelling greater than 2.0 cm

Stress radiographs

• <3.0mm Grade IIIA
• >3.0mm Grade IIIB

Question 4

ankle & foot outcome measures

Answer 4

• Ankle Sprain
  
  • FAAM (ADLs 8,Sport 9)
  • LEFS (MCID 9)
• achilles tendinopathy
  
  • VISA-A
  • FAAM
• Plantar foot pain
  
  • foot function index
  • foot health status questionaire
  • FAAM
  • LEFS

Question 5

Ankle interventions

(acute phase)

Answer 5

• external supports & bracing for more severe (STRONG)
• manual therapy AP (Moderate)
• physical agents
  
  • cryotherapy (STRONG)
  • diathermy (weak)
  • electrotherapy / laser (conflicting)
  • NOT ultrasound (STRONG)
• Therex (STRONG)

Question 6

ankle sprain interventions

(progressive loading / sensorimotor phase)

Answer 6

• manual therapy (STRONG)
• therex (weak)
• sport-related (weak)

Question 7

Ankle sprain risk factors

Answer 7

• hx ankle sprain
• do not
  
  • use an external support
  • warm up (static stretching / dynamic mvmt)
  • have WNL ankle DF ROM
  • participate in a balance/ proprioceptive prevention program if history previous injury

Question 8

Achilles tendinopathy risk factors

Answer 8

• Intrinsic
  
  • abnormal DF ROM
  • abnormal subtalar joint ROM
  • decreased PF strength
  • increased foot pronation
  • abnormal tendon structure
• Extrinsic
  
  • training errors, environmental factors, faulty equipment
• Medical
  
  • obesity
  • hypertension
  • hyperlipidemia
  • diabetes

Question 9

Achilles tendinopathy signs/symptoms

Answer 9

• Achilles tendon tenderness,
• positive arc sign (palpated swelling moves

w/ DF & PF)

• • Royal London Hospital test
    
    • TTP 3cm proximal to insertion with slight PF, decreases with ankle DF

Question 10

Achilles tendinopathy interventions

Answer 10

• Strong
  
  • eccentric loading
• Moderate
  
  • low-level laser
  • iontophoresis
• Weak
  
  • stretching
  • foot orthoses
  • NOT night splint
• Expert opinion
  
  • manual therapy
  • taping
• Conflicting
  
  • heel lift

Question 11

orthotics and…

Answer 11

• LBP: prevention=equivocal; tx = neg
• pain: negative
• plantar fasciiitis
  
  • 3mo dec in pain, no long term >1 yr benefit
  • custom no better than COTS
  • chronic (>20 mo) = short term relief w/ custom
• hallux valgus
  
  • custom orthotics = surgery @ 6 mo
  • surgery > orthotics @ 12 mo
• pes cavus
  
  • no benefit

Question 12

Plantar heel pain

risk factors

Answer 12

• limited DF ROM
• high BMI (non-athletic pop)
• running
• work-related WB actitivities

Question 13

Plantar heel pain

Answer 13

• plantar medial heel pain: most noticeable with initial steps after period of inactivity; also worse with prolonged WB
• heel pain worse with recent increase in WB
• pain with palpation of prox insertion of the plantar fascia
• +windlass test
• • tarsal tunnel
• limited AROM/PROM TCJ DF
• abnormal FPI
• high BMI

Question 14

Plantar heel pain outcomes

Answer 14

• FAAM
• FHSQ
  
  • MCID pain 13; function 7; footwear 7
• FFI
• LEFS
  
  • MCID 8 (100)

Question 15

Plantar heel pain interventions

Answer 15

• STRONG
  
  • MT (joint/STM)
  • Stretching
  • anti-pronation & elastic therapeutic taping
  • Foot orthoses (if +taping)
  • night splints (1-3 months)
• Weak
  
  • low-level laser
  • phonophoresis
  • NOT ultrasound
• Conflicting
  
  • ionto
• Foundational/expert
  
  • weight loss
  • therex
  • NOT TDN