Ankle, lower leg and foot Flashcards
Extra SE qns for ankle and foot
- Clicking / clunking
- Grating(common with OA)
- Snapping
- Giving way (ligaments aren’t suppoting structure very well or muscles are weak)
- Changes to circulation
- Footwear/ orthotics (wear and tear in shoes)
Lateral ankle sprain SE
• PF/ INV injury
• Painful/ swollen – lateral or whole ankle
• Pain with WB
• +/- instability (instability and feeling like it will give way hints at ligament
problems)
Lateral ankle sprain OE
• Obs: swollen & bruised • AROM: ↓ (*PF & INV) • PROM: ↓ (*PF & INV) • Anterior drawer: +ve (depends on grade) (testing ATFL) (if not a grade 3, there will be some end feel) • Palpation – local TOP • (Peroneal structures-resisted PF/EV)
Lateral Ankle Sprain (grade 1 or 2) Management - Acute phase (Days 1-3)
- RICER
- Taping and bracing (can be used to protect the joint)
- Early mobilisation – to P1 pf, df, inv, ev (this helps to decrease pain)
- Protect joint and decrease WB (i.e. crutches)
- EPA
Lateral Ankle Sprain (grade 1 or 2) Management - Sub-acute and Chronic phase
• Stretching -maintain mm. length eg Achilles Tendon
• Strengthening exercise-maintain strength, precription eg peroneals
• Taping, bracing-maintain joint protection
• Gait re-education – biofeedback with mirror (used if someone has developed an
antalgic gait when had sprain; don’t want to cause secondary problems)
• EPA’s - pain
• Massage, DTF, US, EPA’s-promote healing
• Passive mobs-prevent stiffness of non-affected jts (eg. some people lose AP
glide with ankle sprain (reduced DF range)
• Balance exercises-restore and ↑proprioception (can lose proprioception when
damage ligament; if not fixed the person is more prone to injury)
• Goal to Return to full function - full strength and ROM, no Sx, may need
strapping/ brace for RTS
Lateral Ankle Sprain (grade 3) Management
• Immobilise - POP for 6/52
• Surgery - reconstruct lateral ligament or repair with peroneal tendon - POP 6/52
• Rehab post POP or surgery Goal to restore full pain free ROM, strength (eg.
tib ant, gastrocs, soleus)/control and proprioception
Functional ankle instability OE
- Poor control of surrounding muscles poor dynamic stabilising restraints
- Reduced proprioception of ankle joint
Functional ankle instability Management
- Multifactorial management is important
- Improve strength and control of supporting mms
- Proprioception training – wobble board
- Injury prevention – taping / bracing
Other sources of lateral ankle pain
- Osteochondral lesion or # of the talar dome (this can look like a lateral ankle sprain or occur as well as a sprain)
- Inferior tibio-fibular ligament (interosseus lgt) (when go over on ankle, pull fibula down which can cause disruption between the bones)
- Post traumatic synovitis of TCJ or STJ
- Peroneal nerve entrapment
Deltoid Ligament Sprain SE
Mechanism
• EV & ABD injury
• Lots of force needed much less common than LLC
• Often occurs with fractures (due to high force)
• Medial joint may get compressed with LLC sprain
Deltoid Ligament Sprain Management
Treated the same as LLC sprain (recovery takes twice as long) (strengthening
muscles, improving proprioception etc)
Tibialis posterior tendinopathy SE
- Area: Medial ankle & radiating along line of tendon behind medial malleoulus
- Agg: activities causing prolonged stretching into EV (i.e. running)
- Ease: rest
Tibialis posterior tendinopathy OE
- Excessive pronation
- RSC INV – pain
- Stretch: EOR passive eversion - pain
- Tender and swollen along tendon
Flexor hallucis longus tendinopathy SE
- Area: medio-posterior aspect of calc around sustentaculum tali
- Agg: toe-off or fore-foot WB
- Ease: rest
Flexor hallucis longus tendinopathy OE
• RSC F 1st ray (distal phalanx) – pain
• Stretch 1st ray into E – pain
• Palp: Local TOP +/- crepitus (creaky feel of tendon in sheath) over tendon +/-
swelling/ thickening
• Observe people walking up on toes = cause pain if FHL tendinopathy most of
time
Tendinopathy management
• Local Rx: EPA’s, Soft Tissue Massage (STM)
• Stretching
• Strengthening-concentric/eccentric
• Consider contributing factors: -Altered biomechanics-control ?orthotic (eg. So takes off pronation which can put
medial structures on stretch), tape
-Training regime: rate of increase, training too much -Shoes (amount of support etc)
Tarsal Tunnel Syndrome: Posterior Tibial Nerve Entrapment SE
• Area: post to medial malleolus & radiating into foot, heel +/-toes (when it
becomes medial and lateral plantar nerve of foot)
• P&N/numb on sole
• Nature: sharp, deep
• Onset: trauma or excessive pronation (similar to tibialis posterior onset)
Tarsal Tunnel Syndrome: Posterior Tibial Nerve Entrapment OE
• AROM: DF & Ev ↑ pain (position that stretch the nerve as it comes behind the medial malleolus); ↑ with Straight Leg Raise (increases stretch on nerve)
• Tinels test: may be +ve (tap on nerve)
• Neuro: +/- ↓ sensation on sole (area supplied by the nerve)
• Differentiate from S1 nerve root – check Sx (need to be aware that it could be a
local nerve or from a nerve root referring pain)
List the main causes of posterior heel pain
• Achilles tendinopathy (AT) (most common)
• Retrocalcaneal bursitis
• Sever’s disease (especially in children, pulling of tendon as it inserts on
calcaneum)
• Posterior Impingement Syndrome
Types and contributing factors of achilles tendinopathy
2 Types
• Non-insertional (body of AT, a few millimeters above insertion point) (more
common)
• Insertional (adjacent calcaneum)
Contributing factors
• Tibial IR and over pronation (foot more likely to go over into pronation with the
tibial IR)
• Tight calf muscles (Common in runners who don’t stretch enough)
• Change in footwear (eg. Move to less supportive footwear) or rapid ↑in exercise
Achilles tendinopathy SE
- Onset: Gradual/ overuse
- Area: local to AT on/ above insertion - usually medial
- Agg: activity (i.e. running)
- Ease: rest
- 24 Hr: worse in AM (especially in early, inflammatory stages)
Achilles tendinopathy OE
- Obs: pronation on WB (can look at shoe wear)
- RSC: PF or heel raise may reproduce pain
- MLT: calf tight and stretch may reproduce pain
- Palp: local oedema, thickening of AT
Achilles tendinopathy Management
• Local Rx - DTF, EPA’s
• ↑calf flexibility – Stretching (once settled down; degree of stretching progresses
with improvements)
• Eccentric loading exs
- Alfredson protocol for non-insertional AT
- Modified Alfredson for insertional AT (Brukner & Khan 2012)
• Address contributing factors
- Biomechanics of gait/running (eg. looking at hip rotation etc)
- Orthotics and footwear to maintain neutral foot
- Modify training
