Ankle Pathologies Flashcards
Prevalence of Ankle LCL sprains
More common than deltoid ligt sprain
Usually after traumatic event/acute presentation - occurs due to an inversion type injury
Common in teens-40s
Management of Posterior Tibial Tendon Dysfunction
- Rest
- Orthotics (conservative)
- Rehab
- Surgery but not recommended for elderly, obese patients as not necessary; young adult athletes may require surgical opinion
Treatment outcome: can be poor if not treated correctly.
Types of Apohysitis
Osgood Schlatter Disease = Apophysitis occurring at tibial tubercle
Sinding-Larsen-Johansson Syndrome = Apophysitis occurring at patella tendon attachment at apex of patella
Sever’s Disease = Apophysitis occurring at Achille’s tendon attachment on the middle facet of the calcaneus
Risk factors of Plantar Fasciitis
Obesity/overweight
Flatfoot
High arch
Reduced dorsiflexion
DM
RA - connective (soft) tissue disease hence effecting soft tissues
Define Jones #
Fracture to the base of the 5th metatarsal
Polzer Classification = split into 2: Metaphyseal Fracture, Meta-diaphyseal Fracture
Lawrence and Botte classification = split into 3 = Zone 1 (Tuberosity Avulsion #), Zone 2 (Jones #), Zone 3 (Diaphyseal stress #)
Stress # for female athletes
Female athletes developing Relative Energy Deficiency Syndrome (REDS)/ Female Athlete Triad
Risk factors: in teens-20s, High levels of exercise and eating insufficient nutrients to accommodate exercise levels, increasing risk of lowering BMD thus greater risk of stress #
Signs: Low body fat, menstrual cycle stopped/dysfunctional, Previous #, high levels of exercise
Define Avascular Necrosis (AVN)
AVN is condition in which there is loss of blood supply to the bone. Bone is living tissue, hence loss of blood supply, means bone death. If bone death progresses, leads to bone collapse
Clinical presentation of ankle LCL sprains
PC:
Pain/tenderness, swelling local to lat ligt. Esp. ATFL and/or bruising - in more mod-severe cases (ATFL>CFL>PTFL)
Aggravated - Walking or running over uneven ground, Turning sharply, Landing on inverted ankle
Severe/Moderate tears Grade II-III pain on WB, walking and most movements of the ankle
HPC/Previous episodes:
Traumatic = specific injury involving ankle inversion (MOI)
Sudden onset
Can be recurrent
SQs:
Giving way
Swelling- onset or recurrent
Walking over uneven ground
SH:
Sport involving rotation/turning eg. football, rugby, hockey!
Special tests: Anterior drawer test = ATFL injury
Talar tilt test = CFL injury (+ve)
Muscle spasm
Inability bear weight - may indicate # present
Ottawa ankle rules - used to determine if a X-ray is necessary:
Look for pain on weight-bearing at the distal end of fibula and posterior edge of L malleolus and likewise pain on distal 2-3” tibia just proximal to M malleolus
Look for pain on navicular and 5th MT and inability to weight-bear
Site of symptoms may not be diagnostic – multitude of other injuries such as peroneal tendon strains, neural irritation, OCDs, syndesmotic ligament tears, osteochondral lesions of the talus, occult stress fractures, synovitis, adhesions, intra-articular loose bodies, chronic instability, anterolateral impingement, and peroneal tendon pathology
4 radiographic stages of maturation of apophysis
- Cartilaginous (0-11 years)
- Apophyseal (11-14 years)
- Epiphyseal (14-18 years), during which the epiphysis and apophysis coalesce
- Bony (> 18 years)
Prevalence of Jones #
Patient (and clinician) often don’t realise fracture has occurred
May have sprained ankle - pain at LCL but also # 5th MT w/out knowing
Affects base of 5th MT, maybe peroneal swelling, often misdiagnosed as insertional tendinitis.
Can indicate vitamin D deficiency
Diagnosis of Stress #
- Early diagnosis is difficult because - Plain radiograph could only be positive in less than 10% of cases.
- Hence for early signs MRI is the gold standard test looking for bone marrow oedema.
- Physiotherapists should have high index of clinical suspicion in athletes presenting history of gradual onset of symptoms VS sudden onset (traumatic #)
Clinical presentation of Plantar Fasciitis
PC:
Pain affecting the heel, worse in the morning and after weight-bearing all day
Symptom location - Medial origin of medial band of plantar fascia; Medial calcaneal tubercle attachment of PF
HPC:
Onset gradual over weeks/months
May be associated with traumatic incident to PF
FSH:
Sport or job that involves weight bearing
SQs:
P&Ns or Numbness
24 hour aggs
First few steps am, or after prolonged rest
Running, dancing, jumping, prolonged standing/walking
Test - Palpation with twisting motion to MCT will cause discomfort and pain; palpation during ext of toes - put plantar aponeurosis on a stretch
Define Apophysitis
XS or repetitive traction in adolescence may result in micro-trauma and chronic irritation causing thickening and pain of the apophysis
Common in paediatric patient aged between 12-16 years - tend to be sport individuals
Symptoms of AVN
Symptoms may include stiffness in the hip, night pain, limp, pain in the groin, buttocks, front of thigh.
Define a osteochondral defect
An osteochondral defect refers to a focal area of damage that involves both the cartilage and a piece of underlying bone
Define Plantar Fascitis
Traditionally ‘inflammation of the plantar aponeurosis’
Currently, syndrome that may comprise more than 1 condition
Physiotherapy management of ankle LCL sprains
treat same as soft tissue injury: Reduce swelling (ICE, PRICE, PROTECT)
Functional treatment (More effective in short and long term than immobilisation):
Proprioception exercises - those w/ proprioceptive rehab and strengthening of the evertors (peronei) have lower risk of recurrence
Ankle exercises + external support (semi-rigid brace, tubigrip, tape etc)
OMs - reduced swelling, return to work and sport, increased ankle stability
Immobilisation is still considered an option when pain is severe and patients are unable to WB in the absence of a #
Other: Surgery - may increase stability and speed up return to sport but balanced against risks of surgery.
Ice - unlikely to be effective
US - unlikely to be effective PSWD - unknown effectiveness
MWM’s- significant increases in ROM DF immediately post treatment in sub-acute (1-12 weeks) ankle sprains
Management of Jones #
Usually repairs on its own with immobilisation (air cast) but sometimes requires surgical fix if union doesn’t occur
Recovery 4-16 weeks dependent on intervention
Treatment plan is debatable depending on classification used
Define a chondral defect
A chondral defect refers to a focal area of damage to the articular cartilage (the cartilage that lines the end of the bones).
Causes of Osteochondral defect
Can occur acutely or develop as a result of several chronic conditions including:
○ Separation of the osteochondral fragment caused by an acute traumatic injury or as the end result of an unstable fragment in osteochondritis dissecans (small segments of bone begins to separate due to lack of blood supply)
○ Acute osteochondral impaction of the bone with resultant contour deformity.
○ A collapse of the subchondral bone in a subchondral insufficiency fracture (SIF) or avascular necrosis (AVN) or a bone collapse uncovering a large subchondral cyst (can occur from OA)
Prevalence of Plantar Fasciitis
Common foot disorder - 15% of all foot pathologies (Hyland et al, 2006)
Very common in sports injuries and sedentary population
Often misdiagnosed (sinus tarsi syndrome)
Pathology of subchondral cyst
The synovial fluid intrusion theory -proposes that articular surface defects and increased intra-articular pressure allow intrusion of synovial fluid into the bone, leading to formation of cavities.
The bone contusion theory - according to which non-communicating cysts arise from subchondral foci of bone necrosis that are the result of opposing articular surfaces coming in contact with each other
Prevalence of Posterior Tibial Tendon Dysfunction
Posterior tibial tendon dysfunction typically occurs in obese, middle-aged women with up to 10% prevalence in this group.
Conditions such as diabetes, hypertension, obesity, previous surgery, foot/ankle trauma and steroid use is found in up to 60% of patients.
Define Apophysis
A normal developmental outgrowth of a bone, which fuses later in adult development
Found where major tendons and ligaments attach to bone, e.g. the tibial tubercle apophysis is an insertion for the patellar tendon
Clinical Presentation of Posterior Tibial Tendon Dysfunction
Typically present with pain along posterior medial malleolus extending to the navicular
May have lowered medial longitudinal arch - flat foot if tendon is ruptured/dysfunctional
Test: tiptoe single phase support = Clinician stands behind - observe calcaneus (heel) turns inwards as they raise their tiptoes - observation of high foot varus (ADD) - If tendon is ruptured this is not observed
Prevalence of Stress #
Common among joggers and runners
Metatarsals & tibia = most common # sites
Estimated 1% # at femoral neck - Early recognition is required to prevent progression of # of femoral neck because if it becomes displaced -> avascular necrosis of femur
Symptoms of femoral neck stress # = Exertional groin pain, worsening on exercising; pain at full hip ROM
Management of Plantar Fasciitis
85% cases respond to conservative treatment alone; 15% require surgery
Taping – many different techniques described for PF
Medial arch support for the overpronated foot
Correction of calcaneal valgus
Effectiveness unknown
Stretching of PF, hamstrings, and calf muscles - 72% improved with stretching alone which increased to 88% with heel insert. 256 subjects with heel pain over 8 weeks
Strengthening of tibialis post, intrinsics may be beneficial but lack of evidence
Other:
US
Medial arch support Rest Phonophoresis /iontophoresis Ice/compression to reduce inflammation
Subtalar joint accessory mobilisations Heel pad
*Steroid injection-may be harmful risk of rupture.
NSAID’s Acupuncture Heat
Common LL #s
NOF- risk of AVN, # Acetabulum, Long bone #, Tibial Plateau #, OCD – Osteochondral defects, Weber #, Stress #
Management of LL #s
Aim - stabilise #, Restore Function
- Gait-re-ed - use of parallel bars, zimmer frames, crutches
- ROM - try maintain as much in early stages
- Strength - After consolidation - WB activity, progressive strengthening
- Pain relief
Common LL muscle injuries
Hamstrings>Calf>Groin>Quads
MOI of muscle injuries
Sport/activity dependent
Proximal muscles MOI - high speed contractions usually kick in during high level activities
Distal muscles MOI - can be lower speed contraction as they are active during all levels of activity.
Achilles tendon rupture/calf injuries MOI
Extension of knee with DF (all eccentric PF work) followed by push off
Clinical presentation of Achilles tendon rupture
Resting position in knee flex/ext - more DF
Lack of or reduced End feel and increased ROM DF
Tendon palpation
Visibility of tendon rupture - as a dip
Positive Squeeze/Thompson test
Common LL pathologies
Sprains (ligs):
- Knee (ACL/PCL, MCL/LCL)
- Ankle sprains low (LLS – ATFL and CFL) and high (syndesmosis injuries)
Adolescents:
- OGS, SLJ’s, Perthe’s, SFE’s (Slipped Femoral Epiphysis), Sever’s
Bone:
- Stress #s
- # s - # NOF- risk of AVN, # Acetabulum, Long bone #, Tibial Plateau #, OCD – Osteochondral defects, Weber #, Stress
Vascular:
- Arterial = PVT, arterial entrapment
- Venous = DVT
Muscle/Tendon:
- Tendinopathies – Gluteal, Achilles, Plantarfascia and PTTD. Tendon rupture (Achilles)
- Muscle Strains - hamstring>calf>groin>quads
Joint:
- Degenerative - OA – HIP>Knee> Ankle, Joint replacements
- Inflammatory
- Traumatic
- Joint disorders – FAI,PFPS, meniscal tears
