ankle & foot soft tissue injuries Flashcards
in which position is the ankle **most & least stable **in?
- most stable - dorsiflexion
- least stable - plantar flexion
what type of ankle injury is the most common & by what mechanism does it occur by?
- lateral ligament sprain
- occurs via inversion and plantar flexion (activities with quick change of direction, uneven surfaces etc)
out of the 3 lateral ankle ligaments, which one is most often affected, and after that which ligament can follow ?
- anterior talo-fibular ligament (ATFL)
- CFL ligament after
what us a syndesmosis sprain?
what is it also called?
- also called a high ankle sprain
- involves the ligaments between the distal tibia and fibula at the distal tibiofibular syndesmosis
what is the function of the syndesmosis joint?
- provides** strong stabilisation** and **dynamic support **to the ankle
- maintains the** integrity **between the distal tibia and fibula
what are examples of tests that cna be done to test the distal tib-fib joint / syndesmosis?
- squeeze test
- external rotation stress test
what are examples of clinical features of a lateral ankle sprain?
- history with a plantar flexion/ inversion injury
- pain over area
- **weight bearing may be affected **
* bruising and tenderness - reduced ROM initially, esp PF and Inv
- positive stress tests eg talar tilts
- ensure to outrule fracture
what are the ottawa ankle rules?
- important rules that a physio must test with an ankle injury to ensure there is no fracture
- careful around malleolar zones, mid foot etc
what are the signs and symptoms of a grade I mild ankle sprain/tear?
- point tenderness
- minimal swelling and bruising
- single ligament involved
- usually ATFL
- no anterior drawer test- not pos
- no or little limp
- little functional loss
what are the signs and symptoms of grade II ankle sprains?
- some bruising
- local swlling
- margins of achilles tendon less defined
- may be pos for anterior drawer
- limp with walking
- unable to run
what are the signs and symptoms for a grade III ankle sprain?
- swelling on both sides of achilles tendon
- may be tenderness medially and laterally
- positive anterior drawer test for ankle
- unable to weight bear fully
- significant pain inhibition - ie patient cant feel pain due to disruption of nociceptors
which ligament does the anterior drawer test test?
ATFL
what does the anterior drawer test for the ankle involve?
- foot relaxed and knee flexed
- examiner stabilises the tib/fib and holds the foot in approx 20 degree PF, draws the talus forwrad
- best tested 4-5 days post injury
what ligament does the talar tilt test test?
- calcanofibular ligament
what does the talar tilt test involve?
- patient is lying in supine
- foot is relaxed and knee is flexed
- tilt the talus into adduction & abduction
what exercise is important for ankle sprains?
- active ROM, progress ROM to restore full range
- strengthening exercise
- balance and proprioception exercise
what effects do manual therapy / mobilisations etc have on an ankle sprain?
- short term effects
what effect do NSAID’s have on ankle sprains?
- short term reduction in pain
- longer use may delay natural healing as inflammation is a necessary component of healing
how long should immobilisations be for grade III ankle sprains?
- max 10 days with rigid support
what is the differnece between mechanical and functional instability?
- mechanical - joint motion** beyond the physiological limits** ie ligament laxity
- functional - joint motion beyond voluntary contorl but within normal physiological limits
what us chronic ankle instability - CAI?
- condition characterised by a recurring giving way of the lateral side of the ankle
what are the key muscle groups for strengthening after the ankle injury?
- plantar flexors
- dorsiflexors
- inverters and evertors
why us proprioception training so important for ankle sprains?
- it can improve how quickly the foot and ankle can respond to unsteadiness
- balance training also heightens muscle strength, coordination and joint motion
by what mechanism do medial ankle ligament injuries happen?
eversion injury
why are medial ankle ligament injuries less common than the lateral ligament injuries?
- as the medial ligament is much stronger
what can a medial ankle ligament injury occur in association with?
- may occur with lateral ligament sprain (if the force is extrememely strong and goes from lateral to medial side )
- fracture of the medial ankle
what is tarsal tunnel syndrome?
entrapment of the posterior tibial nerve as it passes behind the medial malleolus
what are examples of causes of tarsal tunnel syndrome?
- tenosynovitis of the tib posterior tendon
- excessive pronation (toes outwards)
- overuse with excessive ankle movement
- overly tight shoes or laces
- RA
what are examples of clinical features of tarsal tunnel syndrome?
- severe sharp pain into the sole of the foot
- aggravated by WB - walking, running and standing
- can be worse in bed at night due to venous stasis
- may have pins and needles - due to nerve compression
- may have weakness of toe flexors
what does the conservative management of tarsak tunnel syndrome involve?
- pain reflief meds
- local corticosteroid injetion
- correct foot deformity - eg with orthotics
- restore strength if possible
- neural mobilisation
what does the surgical management of tarsal tunnel syndrome involve?
surgical decompression of nerve
what is mortons neuroma?
- benign (non cancerous) tumour of a nerve - the bifurication of the common plantar figital nerve
how can morton’s neuroma occur?
- not clearly established
- chronic trauma theory
- entrapment theory
- ischaemic theory
what are the signs and symptoms of morton’s neuroma?
*** shooting, stabbing or burning **pain
* worse with WB
* feeling like a pebble or lump is stuck under foot
* **pins and needles **and numbness
* made worse by tight shoes, high heels etc
* common at 3rd and 4th metatarsals
what kind of treatment can be very effective for morton’s neuroma?
- corticosteroid injection
what is metatarsalgia?
- plantar pain in metatarsal region
what are examples of causes of metatarsalgia?
- hallux valgus (bunion @ big toe)
- morton’s neuroma
- stress fracture
- arthritis
what are the** signs and symptoms **of metatarsalgia?
- sharp aching or burning pain in the ball of the foot
- worse with WB
- may or may not have tingling or numbness
describe the epidemiology of an achilles tear
- more common in males
- age 25-40 (high energy) and also 60+ (low energy) - more associated with a degenerate process
- may be missed in 25% of patients
- often dont have pain prior to rupture
what are key findings in the subjective exam of an achilles tear?
- acute injury
- sudden onset - with sharp pain
- audible snap or tear
- may report swelling or brusing
what does the physical exam for an achilles tear involve?
- positive thompson test
- decreased plantar flexion (contraction)
- presence of a palable defect (palpation)
- increased pasive ankle dorsiflexion (stretch)
- will find it hard to push off during gait and also do a double or single leg heel raise
what does the surgical managment of an achilles tendon tear involve?
- 0-2 weeks - walking in boot with wedges and use of 2 crutches
- 6-8 weeks boot
- rehab - SL stance, leg press, stationary bike
- by 6 weeks - working on ankle ROM
- no stretching achilles for 6 months
- more than 8 weeks and beyond - shoes with heel lift, seated/standing heel raise 50% weight hearing, PF with theraband
describe the epidemiology of achilles tendinopathy
- males can get it just as much as females
- peak age - 40-59 years
- distance runners and multi-directional sport is most common
- sedentary people
- common with systemic conditions
- morning stiffness
- 1 in 3 report bilateral symptoms
what is noticed with the physical examination of achilles tendinopathy?
contract, palpate and stretch
- pain with double/ single leg heel raise and pain with hop or jump
- pain with ankle dorsiflexion
- pain and thickness at site of tendinopathy
- ROM may be altered
what are the common injuries that can occur in the peroneal tendon (fibularis tendon)?
- tenosynovitis - ie tendon sheath swelling
- tendinopathy - overuse
- tear
- subluxing or dislocating tendons
what is plantar fasciopathy?
- degeneration and over use of the plantar fascia of the sole of the foot
- plantar fascia - strong band of connective tissue that runs from the heel to the metatarsals
what are the potential clinical signs and symptoms of plantar fasciopathy?
- patients report localised heel pain on the medial side
- worse standing after rest especially 1st thing in the morning
- improves during the day
- exacerbated with prolonged walking and exercise
