Ankle/ Foot Flashcards
What are the five theories thought to cause a Morton’s Neuroma?
1- Chronic trauma 2- Ischemic theory 3- intermetatarsal bursistis theory 4- Entrapment theory 5- Pronation theory
What are the clinical findings associated with Morton’s neuroma?
1- burning pain in the plantar 3 R.D. we space
- Pain in toes
- Pain worsened with walking in narrow shoes
- Mulders sign
- Digital nerve stretch test
Describe Mulder’s sign ?
Examiner grasps 1 st and 5th MT’s and squeezes while exerting for pressure at sire of expected lesion with opposite thumb
What is the most common moi for ankle sprains?
- forefoot adduction, hindfoot Ir, ankle inversion in plantar flexion and Er of the leg beyond anatomical constraints
What is the most common ligament injured in ankle sprains?
- up to 73% of injuries involve the ATFL
What is the primary restraint to inversion moment when the ankle is in a plantar flexed ?
The ATFL
Ottawa ankle rules
Ankle: pain in the malleolar zone (AND)
- tenderness at the posterior aspect of the tip of lateral mall. OR
- tenderness at the posterior aspect of the tip of the medial mall, OR
- inability to bear weight immediately and in er
Ottawa foot rules
Foot: Pain in the mid foot zone (AND)
- tenderness at 5th metatarsal base, OR
- tenderness at the navicular bone, OR
- inability to bear weight immediately or in ER
Characteristics of a Grade 1 ankle sprain .
- no loss of function, no ligamentous laxity
- (-) anterior drawer and Talar tilt
- rom decreased by five degrees or less
- recovery 7.2 days
Characteristics of a grade 2 ankle sprain.
- some loss of function, some ligamentous laxity
- (+) anterior drawer, (-) talar tilt,
- decreased rom by >5 degrees , but less than 10
- recovery time 15 days
Characteristics of a grade 3 ankle sprain
- near total loss of function,
- (+) anterior drawer and talar tilt
- recovery: 3A- 30.7 days
- recovery: 3B - 55.4 days
What two functional outcome measures have the strongest evidence for use when examining ankle sprains?
- FAAM
- LEFS
How strong is the evidence to support the single leg hop test when evaluating a patient in the post acute period for ankle sprains?
Moderate evidence to use single leghop test
- diagonal, lateral and direction changes
What tests should not be used for ankle sprains?
Shuttle run,Cocontraction,Up/ down hop,Triple crossover
Single limb hurdle, single limb fwd hop for distance, single limb 6 m hop for time, single limb 30 m hop for time
What is the evidence to support Manual therapy for ankle sprains?
Moderate evidence for:
- stm, joint mobilizations, lymphatic drainage, anterior to posterior talar mobs
Evidence for cryotherapy in ankle sprains?
Strong evidence to support intermittent applications
Should you use ultrasound to treat ankle sprains?
Strong evidence against the use of US
What is the level of evidence for electro therapy and laser therapy for ankle sprains?
Conflicting evidence for both
- do not use
CPR for manual therapy and ankle sprains
- symptoms worse when standing
- symptoms worse in the evening
- navicular drop> 5 mm
- distal tibfib joint hypomobility
Can you recommend lace up braces for prevention of ankle sprains?
- yes, studies support reduced incidence by a factor of 2-3 regardless of sex, age, BMI, competition level
What nerves can be injured with a grade 2- 3 inversion sprain?
Fibular and tibial nerves can show denervation
What are extrinsic Risk factors for acute lateral ankle sprain?
- h/o lateral ankle sprain
- do not use external support
- does not warm up properly
- lack of normal TCJ, DF ROM
- do not participate in balance/ proprioception exercises
What nerve innervates the Achilles’ tendon?
Sural nerve
What are some common signs and symptoms of Achilles tendinopathy?
- Intermittent pain related to exercise
- stiffness or Pain at the beginning of exercise session
- stiffness upon WB after periods of immobility
What tests can you use for Achilles tendinopathy?
- Thompson’s test
- TTP Achilles’ tendon
- decreased PF strength
- arc sign area of palpated swelling moves with DF/PF
- Royal London test - TTP along Achilles’ tendon in PF that decreases in DF
What is the level of evidence to support eccentric exercises for Achilles tendinopathy?
- Strong evidence to support eccentric exercises 3x 15 reps x 12 weeks
What is the level of evidence for iontophoresis with Achilles tendinopathy.
- Moderate evidence for 3 ml dexamethasone
What is the level of evidence to support use of low level laser therapy for Achilles tendinopathy?
- Moderate evidence for use of laser therapy
- 820 nm wavelength x .9 j per point at six points along Achilles’ tendon x 12 sessions over 8 weeks
What is the typical clinical course for Achilles tendinopathy?
- Improvement in function ca be expected in 6-12 weeks
- long term follow up suggest 71-100%are able to return to prior level of activity
- results are more favorable in athletic population
- younger patients(33 years) better than older (48 years)
Can you recommend night splints for Achilles tendinopathy?
- night splints are not beneficial for Achilles tendinopathy
Can you recommend heel lifts fir Achilles tendinopathy?
- contradictory evidence to support use of heel lifts
What two functional outcome measures can be used for examination of Achilles tendinopathy?
- Victorian Institute of Sports Assessment ( VISA- A)
- foot and Ankle Ability Measure (FAAM)
What are the risk factors for plantar fasciitis according to CPG?
- Moderate evidence for:
- BMI 25-30+
- decreased ankle DF
- work related WB activities
What is the clinical course for plantar fasciitis?
- clinical course an be over one year with symptoms lasting from 13.3 to 14.4months
What outcome measures should clinicians use for plantar fasciitis?
- FAAM
- FHSQ
- FFI
- LEFS
- VAS
What interventions have strong evidence to manage Plantar fasciitis?
- Strong evidence for:
- manual therapy- cuboid thrusts, prox./ distal tib fib manipulation
- stretching- 2-3x a day x 3 min
- anti pronation taping- immediate pain reduction up to 3 weeks
- foot orthosis- pre fab or custom 2 weeks to 1 year
- night splints - 1-3 month program
What interventions show weak evidence for management of plantar fasciitis?
- Weak evidence for:
- foot wear
- low level laser therapy
- weight loss management
Should clinicians recommend corticosteroid injection t manage plantar fasciitis?
Weak evidence for injections
- more harm than good
- injection site pain, infection, PF rupture, fat pad atrophy, peripheral nerve damage
Should clinicians use US to treat plantar fasciitis?
No, US can not be recommended for heel pain/ plantar fasciitis.
What are the four stages of posterior tendinitis dysfunction?
- Stage 1- TTP, swelling around tendon, but not foot
- pain with heel raises
- Stage 2- flat foot posture- “too many toes sign”
- damage to spring ligament
- can’t perform heel raise
- Stage 3 - foot flat posture- rigid
- Stage 4- degenerative ankle changes OA - severe foot flat
What is the pathomechanical cause of PF?
Biomechanical stress on PF
- mechanical overload
- high BMI
- tight Achilles
- localized nerve entrapment - medial calcaneal/ Lateral plantar
What is tarsal tunnel syndrome?
Compression of posterior tibial nerve in tarsal tunnel
- posterior to medial malleolus
What are symptoms of tarsal tunnel syndrome?
Pain, parasthesia along plantar surface of foot
- worse with prolonged standing and running
- worse at night
How is tarsal tunnel syndrome diagnosed?
- Tarsal tunnel test, Tinel’s sign
- max DF, eversion and extension of toes while tapping tarsal tunnel
How is tarsal tunnel managed?
- Arch supports
- mobilizations of mid foot
- neural dynamics
- strengthens foot intrinsic
Name for shin splints
Medial tibial stress syndrome
- exercise induced leg pain- better with rest
- diffuse, vague pain
- TTP along distal 2/3 posterior medial border of tibia
Management of medial tibial stress syndrome
- rest,iontophoreseis, phonophoresis, ice massage, US
- ESWT
What are signs of stress fracture in the leg?
- Repetitive stress
- more localized symptoms
- TYP along anterior proximal 1/3 of tibia
- no neurological symptoms
Management of stress fracture
Rest, activity modifications, may be NWB with crutches
Describe the digital nerve stretch
test
Ankles held in PF on examiners knees
- Pain and discomfort in web space of affected foot
What imaging tool is appropriate to diagnose Achilles tendonopathy?
US and MRI are equal in diagnosis g Achilles tendonopathy
What would you expect to find on US for someone with plantar fasciitis?
Thickening of the plantar fascia is sign of plantar fasciitis
- decreases in pain s associated with de tease in thickness of plantar fascia
Causes of tarsal tunnel syndrome
- Overpronation that compress posterior tibial nerve
- often bilateral
- OA of the ankle
- RA
- Diabetes
- Talonavicular coalition
- ganglion cyst
Describe the Sports Ankle Rating System
- used for active population
- consists of quality of life measures, clinical rating score, and single assessment numeric evaluation
- the qol measure assesses the athletes quality of life
- symptoms, work/ school activities, ADL, recreation/ sport activities and lifestyle.
- clinical component assesses gait, motion, strength, stability, single limb balance, and lateral hopping
