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MSPT I > Ankle: Exam 2 > Flashcards

Ankle: Exam 2 Flashcards

1
Q

Lateral Ankle Sprains

MOST COMMON LIGAMENT INJURED

A

ATFL

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2
Q

Lateral Ankle Sprain

MOST common ligament injured THEN….

A

ATFL FIRST

followed by:

CFL, PTFL

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3
Q

Lateral Ankle Sprain

MOI

A

Ankle PF and INversion

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4
Q

Lateral Ankle Sprain

Risk Factors

A
  • Hx of PREV ankle sprain
  • Do NOT use an EXT. Support
  • Do NOT properly warm-up
    • ​timing—-warm up peroneals!!!
  • Do NOT have normal ankle DF ROM
  • Do NOT participate in balance/proprioceptive prevention program when there is a hx of prev. injury
    • ​this is often LAST PART OF REHAB***
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5
Q

Lateral Ankle Sprain

Clinical Presentation

A
  • Localized pain @ Anterolateral ankle
    • ​ATFL>CFL>PTFL
  • Effusion (edema)
  • POSSIBLE diff. bearing weight
  • POSSIBLE ecchymosis (bruising)
    • ​why?
      • ​sm. blood vessels ruptured during FIRST injury——following injuries have LESS ecchymosis****
  • (+) Ant. Drawer Test and/or Talar Tilt Test
    • ​remember Stabilize Medially if TESTING LATERAL SIDE
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6
Q

Anterior Drawer Test of the Ankle

  • If assessing Medial (Deltoid) Ankle
    • ​Stabilize laterally
  • If assessing Lateral Ankle
    • ​Stabilize medially
A
  • Tests for injury of ATFL
    • ​can also use for Deltoid Lig.
  • Pt. seated over edge of table w/ ​ankle in SLIGHT PF (~20degs)
  • Apply ANT. GLIDE of talus on stabilized tibia
  • (+) Test= excess. translation of one side in comparison to opp. extremity
  • Discuss/Understand Diff:
    • Lateral aspect of talus translates too far anteriorly ==== Lat. Ankle sprain
    • ​ENTIRE TALUS translates too far anteriorly==Lat & Med. side injury****
  • Sn=.58
    • 42% FN’s
  • Sp= 1.00
    • 100% Negs are Negative
  • +LR=INF (want >10)
    • VERY SURE YOU HAVE IT IF (+)
  • -LR= .42 (want
    • NOT SMALL ENOUGH TO BE SIG.
    • cannot put a ton of stock in a negative test
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7
Q

Talar Tilt Test

*For Lateral Ankle sprain

A
  • Tests for injury to the CFL
  • pt lies SUPINE w/ ankle in neutral
  • examiner brings ankle into INVERSION
  • (+) Test= excess. motion compared to uninvolved side
  • Sn= .50
    • 50% FN’s
  • Sp= .88
    • 12% FP’s
  • +LR= 4.00
    • want >10
  • -LR= .57
    • want
    • cannot put a ton of stock into a negative test
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8
Q

Lateral Ankle Sprain

Interventions: depends on severity

A
  • RICE (24-48hrs or longer)
  • Bracing
    • aircast, Swedo, etc..
    • taping as indicated
  • Crutches
    • IF unable to WB w/out pain
  • Gradual active ankle ROM w/in limits of pain
  • Gradual PREs w/in limits of pain
    • ​DF, EV****
  • Gradual WB w/in limits of pain
  • Balance/Proprioception ex’s
  • Gradual progression of walking, running
  • Manual Therapy as indicated
    • **to correct Anterior Talar positional fault, OR Ant/Inf. Fibular positional fault
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9
Q

High Ankle Sprain

A
  • Injury to Distal tibiofibular syndesmosis:
    • ​AITFL–ant. inf. tibiofibular lig.
    • PITFL– post. inf. tibiofibular lig.
    • Interosseus lig.
    • Interosseus memb.
  • MOI:
    • 3 proposed MOIs:
        1. ER of foot
          * OR tibia rotating INT. on Planted Foot
        1. Eversion of Talus
        1. Excessive DF
  • Mortise widens too much; Talus becomes unstable w/in mortise
  • Risk factors
    • skiing, football, soccer and other turf sports that involve planting of the foot and cutting
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10
Q

High Ankle Sprain

Clinical Presentation

A
  • Pain localized to AITFL
  • TTP of the AITFL
  • Pain w/ active or passive ER of foot
    • ​DF+EVERSION TEST
  • Pain w/ active or passive forced DF
    • ​DF+EVERSION TEST
  • May have heel-rise gait pattern to AVOID excess. ankle DF/pain
  • Antalgic gait w/ shortened stance phase on injured LE
  • SEVERE swelling is RARE
  • MAY be accompanied by deltoid (med.) lig sprain + Fibular Fx
  • (+) Squeeze Test
    • ​compressing tib/fib together
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11
Q

Squeeze Test for High Ankle Sprain

A
  • pt lies SUPINE or seated w/ leg off edge of table
  • examiner grasps lower leg at midcalf and squeezes tib/fib together
  • (+) if proximal force** causes **distal pain near syndesmosis
    • ​bc Distraction force caused @ distal end when you squeeze PROXIMALLY
  • Sn= .30 (70% FN’s) Sp= .93 (7% FP’s)
  • +LR= 4.60 (want >10) -LR= .75 (want
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12
Q

High Ankle Sprain

Interventions

A
  • Conservative Tx in the absence of fx (Sx for severe cases)
    • ​RICE
    • IMMED. NWB to prevent further injury;
      • progress to WB as pain allows
    • splint/brace/tape for mech. stability as needed
    • GRADUAL progress. of AROM as pain allows
    • GRADUAL progress of strengthening as pain allows
    • GRADUAL progression of balance/proprio training as pain allows
    • Gait training—–include AD if necessary
    • Restore FXN, and return to sport/rec.
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13
Q

Medial (Deltoid Lig.) Ankle Sprain

RARE****

MOI:

A
  • Injury to Deltoid Lig.
  • MOI:
    • ​Eversion of ankle
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14
Q

Medial Ankle Sprain

Eversion Sprain

Clinical Presentation:

A
  • sig. swelling
  • tenderness over medial ankle
  • ecchymosis over medial ankle
  • Pain localized to medial ankle w/ valgus stress
  • INTERVENTION:
    • ​similar to Lat. Ankle Sprain
      • BUT direction of motion to protect is Eversion
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15
Q

Chronic Ankle Instability

A

Recurrent ankle sprains AND repetitive episodes of giving way

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16
Q

Chronic Ankle Instability

Risk Factors

A
  • INCd talar curvature
  • NOT using ext. support
  • NOT performing balance or proprio. ex’s following acute lateral ankle sprain
  • Previous ankle sprain
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17
Q

Chronic Ankle Instability

Clinical Presentation:

A
  • Hx of repeated ankle sprains/giving way
  • Persistent pain
  • DECd postural control
  • INCd instability
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18
Q

Chronic Ankle Instability

Intervention

Non-OP vs

Surgical

A
  • NON-OP—-similar to Lat. Ankle Sprain w/ emphasis on balance training
  • Surgical:
    • ​Lat. Ankle Repair
      • _​_remember “REPAIR” is much less stable and you MUST BE MORE CAREFUL
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19
Q

Lateral Ankle Repair

Indications:

A
  • Chronic ankle sprains or instability
    • elective sx
    • usually those under 40 and athletic
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20
Q

Lateral Ankle Repair

Gen. Sx Procedure

A
  • Lat. incision made to access ATFL/CFL
  • Ligs overlapped and sutured (BE CAREFUL W/ THESE!!!)
  • **First 6 wks MOST important AND vulnerable time for healing repair
    • ​AVOID:
      • ​Inversion & PF
        • ​why????
          • ​bc THIS IS THE MOI!!!!!
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21
Q

Recommended Interventions during Acute/Protected Motion Phase

A
  • EXT. support and progressive WB (AD as needed)
  • Manual therapy
    • soft tissue mobs+jt. mobs
      • ​INCLUDING post. talar glide (for DF)
  • Cryotherapy
  • TherEX
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22
Q

Recommended Interventions during Subacute/Chronic Progressive Loading/Sensorimotor Traning Phase

A
  • Manual Therapy
    • Jt mobs, MWM to improve DF ROM, proprio and WB tolerance
  • TherEX, functional+balance activities
  • Sports related act. training
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23
Q

Ottawa Ankle Rules

A

*developed to det. need for radiographs after acute ankle injury 2* to risk of Fx

  • Sn= 96.4-99% (+ Fx)
    • ​IF they test NEGATIVE—-most likely NEGATIVE!!!
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24
Q

Ottawa Ankle Rules

Ankle X-Ray Series Req’d

Criteria:

A
  • Any pain in Malleolar Zone AND:
      1. Bone tenderness @ Post. edge OR tip of Lat. Malleolus
      1. Bone tenderness @ Post edge OR tip of Med. Malleolus
      1. Inability to bear wt BOTH immed AND in ED
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25
Q

Ottawa Ankle Rules

Foot X-Ray series req’d:

Criteria:

A
  • Any pain in Midfoot Zone AND:
      1. Bone tenderness @ Base of 5th Met.
      1. Bone tenderness @ Navicular
      1. Inability to WB BOTH immed. AND in the ED
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26
Q

Ankle ORIF

PT usually initiated When?

A

~6 weeks

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27
Q

Ankle ORIF

6-8 wks

A
  • RICE
  • Submax iso’s
  • Proprio
  • PROM/AROM
  • Bike
  • STM
  • Progressive WBAT
  • Jt mobs @ 8 wks*****
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28
Q

Ankle ORIF

9-12 wks

A
  • Isotonic (conc/ecc.) bands
  • TM
  • Bike
  • Stairs
  • CKC (closed-kinetic chain) ex’s
  • Balance boards
  • INC jt. mobs Grade
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29
Q

Ankle ORIF:

13-18 weeks

A
  • Cont. phase 1 & 2 goals+interventions
  • Add incline/decline walking, plyo’s, agility, more aggressive strengthening
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30
Q

Ankle ORIF
19+ weeks

A

RETURN TO WORK/SPORT TRAINING!!!

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31
Q

Ankle Fx W/OUT Sx

A
  • WB Status ——depends on physician/surgeon
    • ​OFTEN limtd–PWB or NWB 6-8wks—-Immobilized
      • ​clarify if unsure
  • Casted JUST BELOW FIBULUAR HEAD (common peroneal nerve wraps around fib. head) 3-4wks
    • ​THEN progressed to Cam (Controlled Ankle walker)
  • often NOT referred to PT EARLY in Post-OP phase
    • ​depends on managing physician’s preference
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32
Q

Ankle Fx W/OUT Sx

First 6-8 weeks

During Immobilization

A
  • Crutch OR walker training (with stairs)
    • NOTE: ONLY 2 (crutches/SW) things you can use w/ WB restrictions!!!
  • Progress WB and gait as tolerated/per physician orders
  • hygiene, toe wiggling, AROM of other jts of LE (OKC ex’s for other mm’s)
  • Strengthen ALL other accessible mm’s
    • ​OKC ex’s
  • **obtain clearance for bicycle to maint. aerobic capacity
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33
Q

Ankle Fx W/OUT Sx

6-12 weeks OR 8-12 weeks:

A
  • Progress to FULL WB AND normalize Gait —-TM training
  • Normalize jt mobility (**will be restricted)
  • Normalize ROM
    • ​stretching+PROM
  • Progress strength to FULL
  • Work on balance + proprio
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34
Q

Ankle Fx W/OUT Sx

12-18 weeks:

A
  • plyo’s
  • agility
  • Jog/Run
  • Return to work/sport cond’ing

**NOTE: once Cast is OFF an WB restricts removed—-pt can progress thru all of these activities as tolerated

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35
Q

Osteochondritis Dissecans of the Talus is usually:

A

SUPRAMEDIAL

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36
Q

Osteochondritis Dissecans of the Talus

*part of Subchondral bone has come OFF

Etiology:

A
  • Repetitive micro-trauma, vascular failure, genetic predisposition
  • NON-traumatic lesion often assoc’d w/ HIGH act. lvl in the child or ado.
  • Lesion typ. superomedial Talus *******
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37
Q

Osteochondritis Dissecans of the Talus

Clinical Presentation:

A
  • pain, swelling, popping, clicking, locking, stiffness
  • Point tenderness——-SUPRAMEDIAL TALAR PAIN ****
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38
Q

Osteochondritis Dissecans of the Talus

Intervention:

A
  • Cast
  • Immobilization
  • Protected WB FIRST***
  • Sx IF conservative Tx fails
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39
Q

Osteochondral LESION/Osteochondral Fx of the Talus

NOT OSTEOCHONDRITIS DISSECANS

ACTUALLY INJURY TO CARTILAGE

Usually where?

A

SUPEROLATERAL

Osteo dissecans is superoMED.

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40
Q

Osteochondral _Lesion/_Osteochondral FRACTURE of the Talus

Etiology:

A
  • Traumatic lesion often assoc’d w/ ankle sprain w/ the Foot in INVERSION
  • 2nd thru 4th decade
  • Lesion typ. SUPEROLATERAL talus
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41
Q

Osteochondral Lesion/Osteochondral FRACTURE of Talus

Clinical Presentation:

A
  • MORE ANT. SX’S—-ESP IN PF
    • ​pain
    • swelling
    • popping, click, locking
    • stiffness
    • point tenderness——more ant. esp in PF***
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42
Q

Osteochondral Lesion/Osteochondral FRACTURE of Talus

Interventions:

A
  • Sx—–MORE effective in ADULTS ****
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43
Q

Talar Dome Fx

pain/sx’s MORE_______

A

POSTERIOR

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44
Q

Talar Dome Fx

Etiology

Presentation

Interventions

A

SIMILAR to Osteochondral defects of Talus

which you already KNOW/COVERED!!!

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45
Q

Talar Dome Fx

LATERAL Dome Fx’s almost ALWAYS assoc’d w/___________

A

TRAUMA!!!!!!

LAT has A’s…….Trauma has A’s——REMEMBER IT THIS WAY!!!

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46
Q

Talar Dome Fx

MEDIAL Talar Dome lesion can be _______ OR _______

A

Atraumatic

OR

Traumatic

(Medial likes BOTH!!!)

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47
Q

Tuberosity Avulsion Fx (sharpey’s fibers SO strong that the bone actually fx’s first)

*different from Jones Fx

MOST COMMON Fx involving________

A
  • 5th Metatarsal
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48
Q

Most common Fx involving 5th Metatarsal

A

Tuberosity Avulsion Fx

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49
Q

Tuberosity Avulsion Fx

MOI:

A
  • typ. occurs AFTER forced INversion w/ foot and ankle in PF FROM pull by lat. band of plantar fascia OR fibularis brevis
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50
Q

Tuberosity Avulsion Fx

Clinical Presentation:

Intervention:

A
  • Sudden onset of pain @ base of 5th MET
  • pain w/ WB
  • Tenderness @ base of 5th MET
  • Ecchymosis
  • Swelling

INTERVENTION==> WBAT

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51
Q

Jones Fx

DIFFERENT VS. ______-

A

Tuberosity Avulsion Fx

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52
Q

HOW is Jones Fx different vs. Tuberosity Avulsion Fx?

A
  • Jones Fx
    • fx’s of prox. 5th MET–DISTAL to the tuberosity w/in 1.5cm of the base area
    • Usually HORIZ. and NON-Displaced*****
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53
Q

Jones Fx

MOI:

A
  • Laterally directed—INVERSION twisting of the foot OR fall from standing ht.
    • ​Prone to NON-Union
      • ​usually req’s Sx ***
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54
Q

Jones Fx

Clinical Presentation:

A
  • Sudden pain @ base of 5th MET
  • Diff. WB
  • Ecchymosis, Edema
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55
Q

Jones Fx

Intervention

A
  • usually surgical
    • ​intramedullary nails/screws fixation****
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56
Q

5th MET Fx’s

Differentiating:

A

see pics

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57
Q

Almost ALL _______ can be Tx’d the EXACT SAME WAY

A

Tendiopathies!!!

*Relative rest to DEC aggravating activity

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58
Q

Achilles Tendinopathy

Etiology + Explain diff. b/w Mid-Portion and Insertional Achilles Tendinopathy

A
  • Etiology:
    • overuse related to repetitive microtrauma (excess compression or tensile load or BOTH)
  • Mid-Portion
    • ​MOST COMMON
      • ​Can get MORE DF with mid-portion
      • have them do full ROM (standing on a step) heel raises
  • Insertional
    • ​actually @ the insertion of the Achilles tendon
    • ONLY DO THINGS FROM FLOOR
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59
Q

Achilles Tendinopathy

INtrinsic Risk Factors:

A
  • AGE
    • 41-60yo
  • High BMI
  • Kinesiophobia
  • DECd ankle PF strength
  • abnormal tendon structure
  • Co-Morbidities: Corticosteroid Use!!! (use sparingly)
    • ​Fluoroquinolone use, Statins, HTN
    • Hyperlipidemia, Diabetes
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60
Q

Achilles Tendinopathy

EXtrinsic Risk Factors

A
  • Training Errors!!!
    • ​Abnorm. mvmt patterns,
    • excessive mileage
    • RAPID INC in mileage
    • hill training
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61
Q

Achilles Tendinopathy

Clinical Presentation:

A
  • MALE
  • 30-50yo
  • Localized pain + perceived stiffness in Achilles following a period of inactivity, LESSENS w/ an acute bout of activity (bc you’re warm), and may INC after the activity (bc you’re cooled off)
  • Achilles tendon tenderness
    • insertion point OR more commonly 6cm proximal—(mid portion)
  • DECd PF strength, endurance
  • Pain w/ contraction or stretch of Gastroc/Soleus complex
  • Pain w/ push off, walking UPhill, toe walking
  • **If TRAUMATIC, SEVERE, UNRESPONSIVE to interventions===> MRI to R/O Achilles tear
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62
Q

Dx and Classification of Achilles Tendinopathy

A
  • Arc Sign–> area of palpated swelling MOVES w/ DF and PF
  • Royal London Hospital Test:
    • (+) when tenderness occurs 3cm prox to calcaneus w/ ankle in slight PF, that DECs as ankle is DF
  • Pt reports pain located 2-6cm prox to Achilles insertion——-began gradually
  • Pain w/ palpation of midportion of the tendon to Dx midportion Achilles tendinopathy
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63
Q

Swelling in ONE spot while tendon moves

A

Tenosynovitis

64
Q

Three Options often available to the PT when treating a pt

A
  1. Treat
  2. Treat and Refer
  3. Refer
65
Q

CPG Decision Tree

Component 1: Medical Screening

Component 2: Classify Condition (includes Pt Exam)

Component 3: Determination of Irritability Stage

A
  • Eval and see if approp for PT
  • classify cond.
  • Pt exam
    • PT Dx or Diff Dx
  • Determine irritability!!!
66
Q

CPG Decision Tree

Component 4: Outcome Measures

Looking @ tests

A
  • Measures to assess lvl of functioning, presence of assoc’d phys. impairments to address w/ tx, response to tx.
67
Q

A Note about Outcome Measures

Region Specific vs. Condition Specific

A
  • Region Specific
    • ​FAAM or LEFS (LE function)
      • specific to foot AND ankle
      • taking a more regional approach
  • Condition Specific
    • ​VISA-A is for Achilles tendinopathy
      • ​specific to THE CONDITION of Achilles tendinopathy
      • zoning in on that ONE thing!!!
68
Q

CPG Decision Tree

Component 5: Intervention Strategies

*Irritability*

A
  • Acute vs. NON-Acute Dx Indicators
69
Q

CPG Decision Tree

Re-Evaluate

A
  • Pt goals Met vs. NOT improving
70
Q

NOTE:

When treating a patient…..

*REMEMBER THIS!!!

A

If you do not make them more symptomatic @ some point (or REALLY push their limits)……you are probably not pushing them hard enough!!!

*do this @ least once so you set a boundary!!!

71
Q

Achilles Tendinopathy

Interventions:

A
  • Reduce aggravating factors
    • ​gradually Re-load tendon to tolerance
  • Complete rest NOT INDICATED; Cont. activity to tolerance
  • Eccentric loading OR heavy load, slow speed (conc/ecc.) ex. program for Gastroc/Soleus complex
  • Stretching of ankle PF’s
    • w/ knee flexed (soleus)
    • w/ knee extended (gastroc + soleus)
    • *only if limtd ankle DF ROM/flex found on exam
  • NMSK re-ed. targeting LE impairments that INC load on Achilles
  • Manual therapy—-jt mobs and STM
  • Modalities:
    • ​Iontophoresis w/ dexamethosone
      • ​low lvl laser therapy evidence contradictory—–NOT GREAT
  • RIGID (not elastic) taping
  • Progressive return to PLOF and activity
  • ***Contradictory evidence for heel lifts and orthoses*
    • ​Night Splints NOT RECOMMENDED!!!
72
Q

MOST COMMONLY RUPTURED TENDON

A

Achilles Tendon Rupture

73
Q

Achilles Tendon Rupture

A
  • MOST commonly ruptured tendon!
    • degen changes (tendinosis) in tendon present from overload due to repetitive microtrauma
74
Q

Achilles Tendon Rupture

MOI:

A
  • Push off in knee EXT.
    • ​sprinting/jumping
  • Sudden DF in full WB
    • ​fall, trip UP steps
  • Landing on PF foot from a height
75
Q

Achilles Tendon Rupture

Risk Factors

A
  • Sports
  • Males***
  • 30-40yo
  • Box jumps the wrong way!!!
76
Q

Achilles Tendon Rupture

Clinical Presentation

A
  • Assoc’d w/ sudden pain, inability to WB, weakness of affected ankle
  • (+) Thompson Test
  • DECd ankle PF strength
  • Palpable gap
77
Q

Achilles Tendon Rupture

Interventions:

A

Sx repair is favored to minimize risk of re-rupture

78
Q

Thompson Test

For Achilles Rupture

The “Squeeze calf” one…

if (+)=== probably torn

if (-)=== probably NOT torn

A
  • Tests for Achilles Tendon Rupture
  • pt lies PRONE
  • squeeze calf
  • (+) Test= ABSENCE of PF when mm is squeezed

Sn= .96 (4% FN’s)

Sp= .93 (7% FP’s)

+LR= 13.47 (strong, want >10)

-LR= .04 (strong, want

79
Q

Achilles Tendon Repair

Traditional rehab models vs. Early motion models

A

*we are now MORE @ early motion models

  • Commonalities:
    • Protection of the repair EARLY ON w/:
      • ​Protected WB—– 4-8wks
      • AVOIDANCE of excess. ankle DF ROM
      • AVOIDANCE of resisted ankle PF
80
Q

Fibular (Peroneal) Tendinopathy

*think Lateral Everything!!!*

Etiology:

A
  • trauma from Lateral Ankle Sprain OR overuse related to repetitive microtrauma
81
Q

Fibular (Peroneal) Tendinopathy

Clinical Presentation:

*think LATERAL foot and Supinated (rigid) foot

A
  • Pain post OR dist. to lateral malleolus
  • Pain @ fib. longus/brevis path or insertion
  • POSITIVE resisted iso. testing of Eversion in PF
  • Pain w/ Passive stretch into Inversion
  • Pain w/ terminal stance
  • Unilateral heel rise painful
  • Pain w/ fig. 8 walk OR walking on sides of feet (in constant INversion)
82
Q

Fibular (Peroneal) Tendinopathy

Risk Factors

A
  • Pes Cavus (like a cave)= high arch
  • Rearfoot Varus/Forefoot Varus/Excessive supination
    • ​== Rigid Foot
  • INCd training or act. involving repetitive and/or high power toe off w/ lateral motion
83
Q

Fibular (Peroneal) Tendinopathy

Interventions:

A

SAME as other tendinopathies

84
Q

Tom, Dick, Harry

all go past what?

A

ALL pass through medial malleolus

85
Q

Posterior Tibialis Tendinopathy

*Think MEDIAL foot!!!*

Etiology:

A
  • OVERUSE related to repetitive microtrauma
86
Q

Posterior Tib. Tendinopathy

**think MEDIAL FOOT, think PRONATED (flat) foot!!!*

Risk Factors:

A
  • FEMALE
  • >40yo
  • Pronated foot—-Pes Planus
  • Obesity
  • excess walking, running, standing, stairs
  • ***Can lead to PTSS (post. tib stress syndrome) AND adult onset flat foot
    • ​PTSS—> mm pulls on medial border tibia
87
Q

Post Tib. Tendinopathy

**Think MEDIAL foot, think Flat foot, think pain trying to CREATE an arch!!!*

Clinical Presentation:

A
  • Pain and swelling post. to MEDIAL malleolus
  • Pain WORSE w/ WB
  • Pain/weakness w/ resisted iso. INVERSION/PF
  • Pain/weakness w/ resisted Forefoot ADDuction
  • “Too many Toes sign”—- very ER foot
  • Pain w/ S/L heel raise OR inability to perform S/L heel raise
  • Lacks normal INversion when rising up on toes*****
    • ​compare sides
  • Ache after walking long distances
  • Pain w/ stretch of Post. Tib
88
Q

Post. Tib. Tendinopathy vs. Flexor Hallucis Longus Tendinopathy

Differentiating?

A

FHL Tendinopathy would cause pain in GREAT TOE bc inserts there !

89
Q

Too many toes sign:

A

see pics

note: calcaneal valgus

90
Q

Post Tib Tendinopathy

Interventions:

A
  • NO DIFF. vs. other tendinopathies
  • Reduce aggravating factors, Gradually reload tendons
  • RICE during acute phase
  • Initial use of brace to UNLOAD tendons, followed by transition to in-shoe orthotic
  • PREs—-ECC. ex’s preferred***
    • ​Slow, controlled loading of tendon is idea
  • Stretching in neut. foot pos.
  • Progress to functional acts.
91
Q

Medial Tibial Stress Syndrome

AKA

A

“True Shin Splints”

92
Q

Medial Tibial Stress Syndrome

aka

True Shin Splints

Pain along____________

A
  • Pain along Posteromedial border of tibia DURING EXERCISE ——*Excludes compartment syndrome & stress fx
93
Q

Medial Tibial Stress Syndrome

aka

True Shin Splints

Theories on Cause?

A
  • Differing Theories:
    • Thought to be chronic periosteal inflammation due to pull of mm’s on tibia
94
Q

Medial Tibial Stress syndrome

aka True Shin Splints

Risk Factors

A
  • athletes who part. in intense, repetitive WB acts.
  • Training errors
  • Biomech. Abnorms:
    • INC pronation
    • INC hip ER/IR
  • FEMALES
  • higher BMI
  • Prev. LE injury
    • ​hx stress fx’s, hx of MTSS
95
Q

MTSS

True Shin Splints

Clinical Present:

A
  • Exercise induced leg pain along posteromedial border of Tibia
    • ​***anterolat is more Ant. Tib Tendinopathy***
  • Pain w/ initiation of act. that subsides w/ cont’d ex BUT RETURNS LATER during act.
  • Pain w/ palpation of dist. 2/3 posteromedial tibial border spread over @ least 5 cm
96
Q

MTSS
True Shin Splints

Interventions:

A
  • Relative rest
    • not really rest, “Active rest”
  • Ice, NSAIDs
  • Modify source of rep. stress
    • ​can be hard/uneven surfs, duration/intensity/freq of training
  • Approp footwear
    • ​support+shock absorb.
  • Orthotics to correct overpronation
  • Stretch/strengthen as tolerated
  • Progressive, gradual return to running/sport
  • ***Often EARLY return to running/activity OR inad. rest DELAYS HEALING
    • ​Feel better so try to return TOO quickly!!!
97
Q

Chronic Exertional Compartment Syndrome

A
  • Lower leg pain DURING EXERCISE due to INC in tissue pressure w/in the confinement of a closed fascial space
98
Q

Chronic Exertional Compartment Syndrome

MM volume can inc up to 20% of its resting size during ex…… how does this cause or exacerbate CECS

A
  • INC in internal pressure w/in fascial compartment
99
Q

Chronic Exertional Compartment Syndrome

5 Osteofascial Compartments:

A
    1. Anterior
    1. Lateral
    1. Superficial Posterior
    1. Deep Posterior
    1. Posterior Tibialis
100
Q

Chronic Exertional Compartment Syndrome

_________compartment MOST COMMON site

A

Anterior Compartment most common

101
Q

Chronic Exertional Compartment Syndrome

Clinical Presentation:

A
  • Development of pain:
    • ​SAME time, distance, intensity of exercise (you notice it comes on @ predictable time)
    • INCs w/ continuation of ex.
    • Resolves after rest pd.
  • Pain—> burning, aching, pressure
  • N/T (numb/tingling) in distribution of nerve running thru compartment
  • Pain on palpation of mm’s involved
  • Pain w/ passive stretch of mm
  • Firmness of involved compartments
102
Q

Chronic Exertional Compartment Syndrome

Clinical Presentation

WEAKNESS (and weakness of specific motion and what that means)

A
  • Weakness of affected mm:
    • ​Weakness of DF==> ANT. compartment
    • Weakness of Eversion==> LAT. compartment
    • Weakness of PF==> POST. compartment
103
Q

Chronic Exertional Compartment Syndrome

Interventions:

Sx vs. NON-OP

A
  • Sx:
    • Fasciotomy (cut into fascia to releive pressure)
      • only definitive intervention*
  • Non-OP (emerging/litte evidence)
    • ​Relative rest
    • Ice, anti-inflamms
    • Stretching of involvd mm’s
    • AVOID running on hard surfs., change footwear, and biomechs of running
    • Orthotics
    • Soft-tissue tech’s
104
Q

Exertional Compartment Syndrome

vs.

Shin Splints (Medial Tibial Stress Syndrome) —-more posteromedial tibia

A

see chart

105
Q

W/ Stress Fx’s

MOST common location?

A

Tibial Shaft

106
Q

Stress Fx’s

Tibial shaft MOST COMMON

Etiology?

A
  • result of excess repetitive stress
    • ​bone mineral resorption EXCEEDS deposition
      • ​==> Fatigue Fx
107
Q

Stress Fx

Tibial shaft MOST common

INtrinsic Risk Factors:

A
  • Poor phys. conditioning
  • FEMALES
  • Hormonal disorder
  • DECd bone density
  • DECd mm mass
108
Q

Stress Fx’s

EXtrinsic Risk Factors

A
  • Running/jumping sports
  • Rapid INC in training
  • Running on uneven surfs.
  • Poor footwear
  • Old running shoes:
    • >6mos or 300mi.
  • Poor nutrition–> DECs bone health
    • Vit. D/Calcium
  • Smoking–> DECs bone health
109
Q

Stress Fx’s

Clinical Presentation

A
  • Onset of pain is gradual
  • Initially– pain ONLY while running/during act. and Pain DECs w/ rest
  • Later— pain may persist after exercise and occur during daily activities
  • Focal pain—-> not to be confused w/ Comparment syndrome
  • X-ray usually not positive until 2-8wks of sx’s
  • MRI, CT MORE Sn early on
110
Q

Stress Fx

Interventions:

A
  • Relative rest
  • Shock absorbing insoles may have role in prevention
111
Q

Acute Comparment Syndrome

Medical Emergency!!!!

what is it?

A
  • SAME as exertional compartment syndrome BUT rapid inc’s in Vol. from TRUAMA!
  • Result of swelling or inflamm (usually from Trauma) that causes INC pressure in closed fascial compartments containing mm’s, nerves, vascular supply
  • **MEDICAL EMERGENCY!!!
112
Q

ACUTE Compartment Syndrome

As pressure INCs….

A
  • mm and nerve function impaired AND necrosis of soft tissue develops——w/in 3 hrs
113
Q

Acute Compartment Syndrome

Clinical Presentation: “4 P’s”

(Griffiths, 1948)

A
  1. Pain (severe AND spontaneous; earliest and MOST SENSITIVE sign)
  2. Parasthesia/numbness
  3. Paresis
  4. Pain w/ stretch

*Also DECd/Absent pulses

*Pink skin color

EMERGENCY—-call physician & send to ER!!! ****

114
Q

Acute Compartment Syndrome

Interventions:

MEDICAL EMERGECNY!!!

A
  • Fasciotomy of involved compart.

​

115
Q

Plantar Fasciitis

Etiology:

A
  • Overuse syndrome of the origin of the Plantar Fascia
    • ​Heel bone!!!
  • Repetitive loading of the central band of the plantar fascia develops INTO fasciopathy
116
Q

Plantar Fasciitis

Risk Factors:

A
  • 45-64 yo
  • Obesity (INCd BMI)
  • DECd ankle DF ROM bc now you use more Pronation
  • Job req’ing prolonged time on feet
  • Recent INC in running
  • Flat feet OR High arched feet
117
Q

Plantar Fasciitis

Clinical Presentation:

A
  • Pain in HEEL
    • ​moreso===> Medial Calcaneal Tubercle
      • ​classic sign
  • Insidious onset
  • Pain and diff. walking first thing in the morning OR after pd of NWB
    • ​==> Post-Static Dyskinesia (exactly waht it sounds like!!!)
  • Pain gradually improves @ first w/ activity, but worsens w/ prolonged act.
  • Pain w/ DF/EXT of 1st MTP
    • == Windlass Mech.
  • Sharp pain to palpation @ heel/PF insertion
  • Antalgic Gait:
    • pain w/ Full WB, esp on foot flat and DF (bc now plantar fascia stretched)
    • MAY walk on sides of feet to avoid stretching plantar fascia that occurs during pronation
  • Contractile Testing:
    • strong & pain-free
      • ​*bc plantar fascia is inert tissue—> NOT part of MTU
118
Q

Plantar Fasciitis

What is often present (in the foot)?

A
  • Pes Cavus OR Pes Planus often present
    • ​Pes Planus==Excess Pronation==PF alwaysgetting overstretched
    • Pes Cavus==Supination==PF is short/tight and does NOT lengthen adequately during WB
119
Q

Plantar Fasciitis and X-ray

A
  • X-ray may or may not show heel spur on the medial tuberosity of the calcaneus
120
Q

Tests for Plantar Fasciitis

A

Windlass Test

Passive 1st MTPJ EXT.

121
Q

Windlass Test

Passive 1st MTPJ EXT

A
  • tests for plantar fasciitis
  • knee 90deg. flexion
    • can be WB or NWB
  • stabilize ankle in neut, grasp prox. segment of hallux w/ other hand
  • IP jt is allowed to flex so the FHL mm does not restrict motion
  • First MTPJ is passively DF to end range OR until subj feels pain
  • (+) if test repro’s pts specific pain
  • Sn= 13.6% (87% FN’s)
  • Sp=100% – NO FP’s—-if (+), its there!!!
122
Q

SnNOUT

SpPIN

A
  • SnNOUT
    • Negative result on HIGHLY SENSITIVE test rules OUT
  • SpPIN
    • Positive result on HIGHLY SPECIFIC test rules IN
123
Q

Interventions to Directly Address Plantar Fascia-related Phys Impairs:

A
  • TherEX
    • Stretching:
      • plantar fascia—(fig. 4–> pull up on all toes in DF), gastroc, soleus
  • Manual Therapy
    • Jt mobs LE, emphasis on improving talocrural DF
    • STM plantar fascia, gastroc, soleus myofascia
  • Antipronation taping
  • Foot orthoses
    • prefab OR custom orthoses to support medial arch and cushion heel
    • Heel cushion, footwear and/or orthotics w/ heel cushioning
  • Pt ed.
    • ​Strats. to modify WB loads during work/daily acts
    • footwear to mitigate WB stresses
    • strats to achieve/maint. optimal wt.
  • Night splints 1-3mos
    • ​keeps you IN DF
  • Modals:
    • Iontophoresis, low lvl laser, phonophoresis
124
Q

Elevating the heel for plantar fasciitis during squats

A

Greater excursion of DF

Plantar fascia is now on LESS of a stretch

125
Q

Interventions to Address Lower-limb Phys Impairments Potentially Assoc’d w/ Plantar Fasciitis

Manual Therapy

A
  • Manual therapy:
    • Jt mobs AND manual stretching to restore normal 1st MTPJ, tarsometatarsal jts, talocalcaneal, talocrural, knee & hip mobility
    • STM+manual stretching to restore normal mm length of calf, thigh, & hip myofascia that are req’d @ Terminal Stance​
126
Q

Interventions to Address Lower-limb Phys. Impairments Pot. Assoc’d w/ Plantar Fasciitis

TherEX and Neuromuscular Re-Ed

A
  • Strengthen/training mm’s that work eccentrically to control pronatory tendencies (remember P.DEAB) and improve ability to attenuate/absorb WB forces
    • ​1. Mid-tarsal Pronation== Post. Tib and Fib. Longus work ecc.
      1. Ankle PF== Ant. Tib works ecc.
      1. Knee flexion==Quads work ecc.
      1. Hip ADD.== Glute med works ecc.
      1. Lower Limb IR==hip ER work ecc @ LR to lessen
127
Q

Pro-Stretch

A

just remember to associate this w/ Plantar Fasciitis

128
Q

Tarsal Tunnel Syndrome

A

Immediately you think Neurological sx’s !!!

N/T

Sensory impairs!!!!!!!

129
Q

Tarsal Tunnel Syndrome

Etiology:

A
  • Focal, compressive neuropathy of the post. tibial nerve OR one of its assoc’d branches
130
Q

Tarsal Tunnel Syndrome

Contents of Tarsal Tunnel

from AnteroMed to PosteroLat:

A

Tom, Dick And Very Nervous Harry

  • Tib Post
  • FDL
  • Post. Tibial Artery
  • Post. Tibial Nerve
  • FHL

see pic but don’t forget “Very” —vein !

131
Q

Tarsal Tunnel Syndrome

Risk Factors

A
  • sports
  • obesity
  • Foot deformities
    • ​pes planus
      • ​bc now stretching out Tom, Dick, Harry tendons and nerve
  • DM, trauma, inflammation TO area
  • prolooonged standing, walking, new exercise
132
Q

Tarsal Tunnel Syndrome

Clinical Presentation:

A
  • Pain behind Medial Malleolus region
  • Sensory disturbs in Tibial nerve distribution:
    • ​retromalleolar, sole, heel OR digits
    • pain, numb, parasthesias
    • Intrinsic weakness
      • Clawing of toes
        • ​when prolonged
      • Postive Tinel’s Sign
        • ​Bang on the Door!
    • Repro of sx’s w/ passive ankle DF w/ Eversion
    • ​WORSE w/ prolonged walking
133
Q

Tinel’s Sign for Tarsal Tunnel Syndrome

Bang on the Door!

Where?

A
  • Over Posteromedial aspect of the ankle
  • (+) Test= repro of pts sx’s/tingling or parasthesias felt DISTALLY
134
Q

Tarsal Tunnel Syndrome

Interventions:

A
  • RICE 24-48 hrs
    • remember Relative Rest
  • REMOVE aggravating act.
  • Nerve gliding
  • Orthotics if indicated
  • MM stretching
  • Mm strengthening
  • STM in late or chronic stage of rehab
  • US commonly used BUT NO EVIDENCE
  • Correct impairments and address act. limits.
135
Q

Morton’s Neuroma

Whats unique about this?

A

NOT REALLY A NEUROMA!!!

136
Q

Morton’s Neuroma

A
  • Not actually a neuroma!
    • ​It is a thickening of the tissue that surrounds the digital nerve leading to the toes.
      • ​occurs as nerve passes UNDER IMT lig connecting the Metatarsals
        • ​*often b/w 3rd and 4th digits
          • ​*3rd webspace!!!*
137
Q

Morton’s Neuroma

Etiology:

A
  • Result of stress+irritation to the nerve
    • due to excess. toe DF ***
138
Q

Morton’s Neuroma

Risk Factors:

A
  • 8-10x MORE COMMON in Women
    • ​bc of footwear
139
Q

Morton’s Neuroma

Clinical Presentation:

A
  • Mean age: 45-50
  • Sharp/burning pain
  • numbness or feeling of a rock in your shoe @ balls of feet
140
Q

Morton’s Neuroma

Interventions:

A
  • Shoe modification
    • NO high heels or narrow toes
    • orthotics
    • pad that elevates MT head on medial side
    • cortisone inj’s
  • Sx resection ==== last resort
141
Q

Morton’s Neuroma

Thumb Index Finger Squeeze Test

*exactly what it sounds like!

A
  • SUPINE
  • Symptomatic intermetatarsal space is squeezed b/w tips of index finger (dorsal foot) and thumb (plantar foot)
  • Splaying of toes===> indicates correct positioning of fingers and pressure applied
  • (+) Test= pain repro’d
  • Sn= 96%, Sp= 100%
  • PPV= 100%, NPV= 33%
142
Q

Hallux Rigidus/Limitus

A

Limitus==Early stages

Rigidus==When motion MAXIMALLY restricted/absent

143
Q

Hallux Rigidus (late)/Limitus (Early)

what is it?

A
  • Progressive restriction of motion in 1st MTPJ
    • ​ESP into EXT!!!
144
Q

Hallux Rigidus/Limitus

Etiology:

A
  • Progressive degenerative arthritis of 1st MTPJ
  • May be trauma, cumulative micro-trauma, RA or gout
145
Q

Hallux Rigidus (late)/Limitus (early)

Risk factors:

A

FEMALES

146
Q

Hallux Limitus (early)/Rigidus (late)

Clinical Present:

A
  • Pain @ 1st MTPJ
  • Loss of 1st MTPJ EXT. and later…..FLEX
  • DECd toe off, diff w/ heel rise and squat
147
Q

Hallux Limitus/Rigidus

Intervention:

A
  • LIMIT 1st MTPJ motion to protect and remove irritating stress on joint
    • taping, shoe orthotics
  • Manual therapy (jt mobs) to improve 1st MTPJ motion
  • stiff soled, deep toebox shoes
  • Sx:
    • ​Cheilectomy
      • removes bone spurs
    • Prox. Phalanx Osteotomy
      • change pos. of bone
    • Arthrodesis
      • alterations and fusions
148
Q

Hallux Valgus and Bunions

A
  • “Valgus”==> angle of 1st MTP
    • Hallux moves LAT. relative to metatarsal
      • ​up to 20o is common
      • >20-30o==> hallux valgus
  • “Bunions” ==> resultant callous formation, thickened bursa, & bony exostosis on MED. side of 1st MTP
149
Q

Hallux Valgus and Bunions

Risk Factors

A
  • Hereditary, abnorm foot mech’s, high heels, narrow toed shoes, MAY BE RELATED to gout/RA
  • Women>Men
150
Q

Hallux Valgus and Bunions

Interventions:

A
  • Toe spacers, splinting, adaptive footwear, orthotics for correction of foot align.
  • Strengthening ex’s
  • current evidence suggests progression w/out sx correction
151
Q

Bunionectomy

Takeaway: if fusion–> DO NOT TRY TO MOBILIZE A FUSED JOINT!!!

A
  • Over 100 sx procedures for bunions—-little evidence to say one is better than other
    • Gen types:
      • ​Exostectomy
        • removal of part of metatarsal head
      • Realign. of soft tissues around 1st MTPJ
      • Metatarsal Osteotomy
        • removal of sm. wedge of bone
      • Resection Arthroplasty
        • MTPJ bones reshaped
      • Arthrodesis (fusion)
        • fusion of MTPJ
      • Lapidus procedure
        • fusion of midfoot
      • Implant insertion of ALL or PART of an artificial joint
152
Q

Bunionectomy

From a PT perspective….

A

MOST IMPORTANT THING…

  • Pay attn to IF and WHAT jts were Fused
    • ​Otherwise….might end up trying to mobilize a fused joint (BAD IDEA!) OR try to restore motion that cannot be restored
      • ​Contact Surgeon

​

153
Q

Bunionectomy

Progressive ex. program

A
  • Progressive Ex. program initiated EARLY post-OP can help REDUCE comps assoc’d w/ long term immob.
154
Q

Bunionectomy

Maintenance of ROM:

A
  • maint. of ROM in early phases of rehab —-> shown to be beneficial in a study assessing the role of cont. passive motion
155
Q

Bunionectomy

Typ clinical scenario

EBP===>

A
  • pt 12wks after sx referred bc excess stiffness, pain, trouble walking
    • ​surgeons often say “just go walk”
  • EBP== early motion, early progressive ex. program*****
156
Q
A

MSPT I (10 decks)

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