ANKLE/FOOT Flashcards
What are the three arches of the foot?
medial longitudinal
lateral longitudinal
transverse
What is the talometatarsal angle?
line along middle first metatarsal and line of talus on lateral foot
The talometatarsal angle is used to measure
pes cavus (high arch) and pes planus (low arch)
*determining flexible vs rigid arches requires comparing weight bearing and nonweight bearing
Achilles tendinopathy is defined as
painful overuse tendon condition
classified as tendinitis (overuse tendon injury with inflammation) OR tendinosis (tendon degeneration, no inflammatory cells)
Achilles tendinopathy is usually because of ____
excessive overuse
multifactorial causes
acute tendinopathy is usually caused by
trauma, muscle fatigue, excessive use
Primary site of achilles tendon injuries are proximal or distal to tendon insertion? Why?
just proximal to tendons insertion (2-6 cm)
*this is a region of hypovascularity, thus more easily injured
What is the physiological cause of achilles tendinopathy?
not clear/misunderstood. But mostly we know that tendon has failed to heal normally
What are the three muscles that are main stabilizers of the ankle?
fibularis long/brev, tib ant, tib post
What is responsible for pain present with tendinopathy?
increased neurovascularization and presence of increased neurotransmitters around tendon
Who most commonly gets achilles tendinopathy?
male teenage athletes (runners, jumpers)
11% runners, 9% dancers, 5% gymnasts
Achilles tendon injuries are usually due to ____ loading
excessive eccentric loading
*results from training errors, changes in training, increased distance, changes in terrain
What are foot/ankle related contributing factors to achilles tendinopathy?
PRONATION
pes planus (flat feet)
increased rearfoot mobility
weak calf muscles
poor footwear
changes in training program
What are systemic/medicinal/other contributing factors to achilles tendinopathy?
diabetes
obesity
steroid exposure (ligamentous laxity)
hypertension
quinolone antibiotics
What are common signs of achilles tendinopathy?
-pain at insertion site or just above (2-6 cm)
-swelling/thickening of tendon at site of injury
What 3 activities make achilles tendinopathy feel worse?
walking, running, jumping
What makes achilles tendinopathy feel better?
-rest
-NSAIDs (acute, not effective for chronic)
-heel lifts/walking cast boots to control pain with WB activities during acute phase
When do you consider achilles surgery for achilles tendinopathy?
when conservative treatment has failed
*for patients that undergo surgical repair, 75% have favorable outcomes, return to premorbid function.
Are NSAIDs helpful for chronic achilles tendinopathy?
No-found largely ineffective. Helpful for acute cases
Poor outcomes for achilles surgery are associated with what three factors?
age
intertendon lesions
partial tendon ruptures
How do you treat acute achilles tendinitis?
compression
cryotherapy
rest
heel wedge or walking boot
soft tissue mobilization
activity modification
How do you treat chronic achilles tendinopathies?
stretching
night splints
strengthening
orthotic therapy
biomechanical correction
sclerotic therapy
extracorporeal shockwave therapy (ESWT)
Besides stretching, night splints, and correcting abnormal foot mechanics, how do you rehab achilles tendinopathy? What kind of strengthening?
heavy-load eccentric strengthening/training program
What three abnormal foot mechanics predispose people to achilles tendinopathy?
excessive pronation
pes planus
excessive rearfoot motion
The term ankle sprain indicates that what at the ankle has been altered?
structural integrity of the ligaments at the ankle
Ankle sprains most commonly occur among what age demographic of patients?
Younger than 35 (highest occurrence in 15-19 year olds)
What are the three classes of ankle sprains?
- lateral ankle sprains (65%)
- syndesmotic sprains/high ankle sprains (10%)
- medial ankle sprains (5-10%)
What is the most common class of ankle sprain?
lateral ankle sprain
(anterior tibiofibular ligament: ATFL and calcaneal fibular ligament: CFL)
syndesmotic sprains are also called ____ and _______
high ankle sprains and anterior tibiofibular ligament sprains
*injury between tibia and fibula
true or false: medial ankle sprains are the rarest form of sprain
TRUE: injury to deltoid ligament, which is thick
Review Grade I, II, III sprains of ligaments
Grade I: overstretched, microscopically damaged but not torn.
Grade II: partially torn, more significant damage, but no significant instability
Grade III: severe, torn, and instable
The (medial/lateral) ligaments and the ______ capsule are most commonly injured in ankle sprains
LATERAL LIGAMENTS and ANTERIOR-LATERAL capsule
What is the most commonly damaged ligament? Who is 2nd most common?
- ATFL
- Calcaneal-fibular ligament
ankle sprains are usually a result of ____(degeneration or trauma?)
trauma
loaded and stretched too much
A lateral low ankle sprain occurs due to what motion at the ankle?
inversion
(planting foot when running, stepping up or down, stepping on uneven surface)
high ankle/syndesmotic sprains occur when ankle is planted in ____ with ____ rotation
planted in dorsiflexion with lower leg in external rotation
Most syndesmotic/high ankle sprains occur because of
direct contact
medial ankle sprains occur with what motion?
plantar flexion and eversion
common signs of ankle sprains
Ecchymosis (Bruising)
Redness
Tenderness
Instability
Loss of ROM
Inability to bear full weight
syndesmotic/high ankle sprain injuries may mimic pain similar to a _____ ankle sprain
lateral
ankle ligament injuries commonly refer pain locally or distally?
locally in region of the ligament
Pain only occurs with weightbearing for ankle sprains: true or false
false: open chain movements can also increase stress on injured ligament (depends on which motion for which ligament)
Initially, during weight bearing activities, what can help reduce pain for ankle sprains?
immobilization with ankle brace/walking boot
(also ice, NSAIDs, pain meds during acute stage of recovery)
*nonweight bearing is least painful activity
Can you perform gentle joint mobilizations during acute phase of ankle sprains?
yes-helps with pain and edema
Phase one of ankle sprain healing should emphasize
- controlling inflammation
- decrease edema
- protect from more injury
Surgery is usually NOT indicated for ankle sprains except for grade ____ sprains
GRADE III, but not treatment of choice. Usually only after conservative care has failed
Phase 2 stage of healing for ankle sprains emphasize _____
phase 2/subacute stage:
decreasing pain
increasing pain free ROM
limited loss of strength/proprioception
phase 3 of healing for ankle sprains should emphasize
restoring full ROM, strength, proprioception, return to function
______ have been found to assist in formation of collagen during healing process of ankle sprains
early mobilizations
assistive devices, ankle braces, air cast, walking boot, taping can all assist in rehab of _____
ankle sprains
synonyms for shin splints
medial tibial stress syndrome
medial tibial syndrome
stress-related anterior lower leg pain
periostalgia
shin splints is a general term for pain along the _______
distal 2/3 of posterior medial tibia
medial tibial stress syndrome is a specific label for shin splints that excludes diagnoses of _____ or _____
excludes stress fractures or posterior compartment syndrome
shin splints are most common among ____(young/old?) involved in _____
teens to young adults involved in running (or jumping)
*slightly higher in female runners
____are the most common cause of shin splints.
overuse injuries
overuse injuries for shin splints can be classified into what three categories?
- anatomical/biomechanical factors
- training errors
- interaction between shoes and running surfaces
What are the three causes of shin splints?
1. hint-inflammation of the periosteum
2. hint-soleus or gastroc as contributor to medial shin pain?
3. hint-what flexor muscle and fascia are source of shin splint pain?
- periostitis (at posterior medial border of distal tibia)
- SOLEUS (medial shin pain)
- FDL and deep crural fascia (attach to tibia at similar location of shin splint symptoms)
What are microscopic findings in shin splints?
Microscopic findings include vasculitis, increased medial periosteal formation, and cortical hypertrophy along the distal one third of the posterior medial tibial border.
What are three contributing factors to shin splints?
- excessive navicular drop (note: sign of pes planus)
- higher BMI in runners
- increased pronation
What are common symptoms/signs of shin splints?
- pain to palpation over medial to distal third of posterior medial border of tibia
- dull ache, can be intense, pain
- increased pain with weight bearing
- pain may last hours to days after exercise
Where is the pain in shin splints?
mid-distal 3rd of posterior medial tibia
Is pain with shin splints dull or sharp?
dull aching pain, increased by weight bearing. can be intense
Pain with shin splints lasts only minutes after exercise (true or false)
false: can last hours to days
true or false: downhill walking/running is very painful with shin splints because of ECCENTRIC load on pretibial muscles
TRUE. Other aggravating activities: walking, ballistic weight bearing like running/jumping
Besides rest, what else is an ‘easing activity’ for shin splints?
non weight bearing activities
What is the surgical option for shin splints?
Fasciotomy of the superficial posterior compartment of the leg is a common surgical option.
What are two main factors for initial rehab of shin splints?
- activity modification: NONWEIGHT BEARING EXERCISE like swimming or jogging to let tissues heal
- education about risk factor modification (teach early in rehab, reiterate at discharge)
*also decreasing inflammation with modalities!
strength, ROM, endurance, and proprioceptive impairments and contributing factors should be addressed during rehab of shin splints (true/false)
true. Also, external devices like taping/orthotics if needed.
REHAB SUMMARY: activity mod, non weightbearing ex, education, strength/ROM, endurance, proprioceptive impairements, taping/orthotics, modalities
what can decrease inflammation in rehab of shin splints?
cold/hot pack, ultrasound, e-stim
exercises should be done in pain free range
Once inflammation of shin splints decreases, focus on stretching to improve ____ and decrease _______
improve dorsiflexion and decrease pronation
*strengthening muscles that control pronation!!!
rehab protocol for shin splints: mobilizing a restricted ____ joint to improve dorsiflexion may help decrease pronation
talocrural joint
selective activation of ______(which muscle?) can assist in controlling pronation in treating SHIN SPLINTS
tibialis posterior. (slide says wearing custom orthotics/shoes can improve selective activation of tibialis posterior)
true or false: advice on footwear to reduce shin splints
runners should replace their shoes every 300 miles
true
true or false: advice on footwear to reduce shin splints
people with high arched feet should use shoes with max cushioning
true
people with flexible feet should use shoes that provide support/motion control
true
synonyms for plantar fascitis
painful heel syndrome
runner/joggers heel
heel spur syndrome
traction periostitis of plantar fascia
definition of plantar fascitis
inflammation of plantar fascia, most common at proximal insertion of medial tubercle of calcaneus
note: active inflammation not necessary to be considered plantar fasciitis
What is a common co-finding in plantar fasciitis?
bone spurs
*note: no evidence this is the pain generating structure in plantar fasciitis
Plantar fasciitis is caused by ______
chronic overuse
(causes repetitive microtears and thus pain)
where is pain most commonly found with plantar fasciitis?
proximal medial edge (but can be anywhere along the course of the plantar fascia)
plantar aponeurosis is most often injured at the (proximal or distal) attachment of the plantar fascia into the (medial/lateral) calcaneal tubercle
proximal attachment of plantar fascia into medial calcaneal tubercle
What are physiological/structural components of plantar fasciitis injuries?
- body weight
- pes cavus or pes planus
- not enough dorsiflexion (HYPOMOBILITY) at talocrural joint
what are external considerations for cause of plantar fasciitis?
-footwear
-change in exercise routine
-type of surface the patient trains on or walks on
True or false: plantar fasciitis is widely accepted to be result of a mechanical abnormality
true (physiologically, no one accepted pathogenesis)
excessive tension throughout plantar fascia causes _______, especially at proximal insertion
chronic inflammation and microtears
*note: presence of inflammation is controversial, since histological findings do not necessarily support inflammatory cells present
________ causes tensile force in plantar fascia, causing microtearing
LOW medial longitudinal arch
Who usually gets plantar fasciitis?
any age, most common in 40-60 years (higher in females)
*obese pts, male runners, athletes also have higher prevalence
Plantar fasciitis is due to ______
OVERUSE W FAULTY BIOMECHANICS
(PRONATED FOOT, OBESITY)
true: plantar fasica allows passive stability of osseous structures when tensioned via rearfoot supination and toe extension
*allows rigid and stable foot
true or false: plantar fasciitis occurs with excessive supination at midfoot
false: excessive pronation at midfoot esp in walking =microtears/degeneration
Pronation is thought to be a compensatory strategy for people who don’t have enough _____ ROM, leading to plantar fasciitis
not enough dorsiflexion ROM
3 causes of increased tensile load to plantar fascia (mechanism of injury in plantar fasciitis)
- obesity
- excessive time on feet
- pathomechanics (like pronation, not enough dorsiflexion)
what are 2 primary risk factors to plantar fasciitis?
*hint: has to do with obesity and pronated foot position
- not enough dorsiflexion ROM (which leads to pronation as compensation)
- BMI greater than 25
common SYMPTOM of plantar fasciitis (pain related)
insidious onset of worsening medial heel pain
(worst in MORNING or after periods of non weight bearing followed by standing/walking)
what are common SIGNS of plantar fasciitis?
pes planus (bc low arch)
limited gastroc/soleus flexibility (bc not good DF)
true or false: first steps in the morning cause pain in people with plantar fasciitis
TRUE: aggravating activity=first steps in AM
note: In extended periods of non/partial weight-bearing positions (e.g., sleeping or sitting,) the plantar fascia is not stressed. On the first steps in the morning, sudden tensioning of the plantar fascia, especially with terminal stance, creates pain
What else causes plantar fasciitis to feel worse?
- direct pressure over heel (insertion of plantar fascia into calcaneus)
- ascending/descending stairs
- prolonged standing, squatting, running, walking barefoot
what makes plantar fasciitis feel better?
positions where plantar fascia isnt tensioned
(sitting/lying or wearing shoes with small heel)
conservative medical management of plantar fasciitis includes:
Extracorporeal shockwave therapy (ESWT)
Local injection of a corticosteroid
Night dorsiflexion splint
Foot orthoses
What is the main focus of PT rehab for plantar fasciitis?
regaining mobility of ankle (talocrural joint) and neuromuscular training (so compensatory stuff causing tension at plantar fascia can be avoided)
You can improve talocrural dorsiflexion by doing lots of things like….
- joint mob at talocrural joint, prox and distal tibiofibular articulations
- STM of gastroc and soleus
- medial long arch or calcaneal taping
- identify if they need foot orthoses
initial rehab exercises for plantar fasciitis stretch _____ and strengthen ______
stretch: gastroc/soleus, plantar fascia
strengthen: postural stabilizers at ankle and hip
strengthen: intrinsic/extrinsic dynamic medial longitudinal arch stabilizers
*also self STM of plantar fascia, balance exercises with preservation of med long arch
joint mobilizations (if they are contributing factors) of ________ help with plantar fasciitis
talocrural
and/or proximal and distal tibiofibular joints
STM/massage to _____ help with plantar fasciitis if lack of dorsiflexion is a cause
gastroc and soleus
*note: STM directly to plantar tissues of foot can help increase circulation and healing
what are long term exercises for plantar fasciitis?
stretching to maintain talocrural dorsiflexion
neuromuscular reeducation, including balance training, to avoid excess stress at midfoot, specifically talonavicular joint
