ankle pathologies Flashcards
what is a primary consequency of hallux valgus?
hypermobility of the 1st MT
what is the main cause of hallux valgus?
hyperpronation during propulsive phases of gait
shoes too narrow which compress the feet
what can hallux valgus be identified clinically?
1st MT is adducted on medial cuneiform relative to midline
1st phalynx is abducted on MT relative to midline
how can hallux valgus be treated
correct for the hyperpronation w/ strenghtening of the intrinsic muscles and posture or orthosis
taping for temporary pain relief
what is plantar fasciopathy?
histological degeneration and deterioration of collagen fibers, increased secretion of ground substance proteins and fibroblast in areas of proliferation
what clientele is affected by plantar fasciopathy?
- very active people
- people w/ a shigh standing workload
what causes plantar fasciopathy?
degenerative causes due to excessive and repeated loading
low arches: increase the stress in order to stabilize the arch
high arches: inability to pronate foot and thus decreased shock absorption and thus increase stress on foot
-poor MTP extension = poor windlass mechanism = increased stress on plantar fascia
-tightness of myofascial structure = increased pronation or increased tension on fascia
what is the most common MOI(s) for plantar fasciopathy?
overuse injury (insidious)
WB activivity s/a running
activities w/ excessive mvmt, foot pronation or stressing/stretching of plantar fascia (MTP in full extension, foot hyperpronated or foot hypersupinated)
what is the pain site for plantar fasciopathy?
medial tuiberosity of calcaneus and extends along the medial border of the plantar fascia
what is the pain pattern for plantar fasciopathy?
pain worse in am or post activity in WB
if more severe: pain w/ NWB
pain increases w/ mvmt stretching/stressing of the plantar fascia
hwta can be noticed in gait in a foot w/ plantar fasciopathy?
hypersupination or hyperpronation
what is the effect of having a foot hypersupinated
poor motion of tbhe bones thus excessive load on the fascia
what is the effec of foot hyperpronated?
hypermobility
how is the ROM in a foot w/ plantar fasciopathy?
MTPs full extension might be painful and stiff
how is palpation for plantar fasciopathy?
pain on medial tubercle of calcaneuse
might have a heel sput; which is generally painless
what results from flexibility testing for plantar fasciopathy
stiffness
what test can be used to test flexibility in plantar fasciopathy? explain the test?
windlass test
pt in WB is asked to bring hallux into full extension, the arch should rise
might be painful
if nothing happens or is delayed –> weakness
if needs lots of force before being initiated –> stiffness of the fascia
can imaging be used for plantar fasciopathy?
only is conservative Rx is uneffective it is used to detect changes in the facia or heel spurs
how can we decrease pain in plantar fasciopathy
- avoid aggravationlload reduction
- ice and NSAIDs to reduce inflmmation
- taping to elevated fascia
when is stretching used as a tx option for plantar fascipathy? what stretches cn be done
when the plantar fascia is stiff w/ windlass test
-PROM MTP exrtension, full ankle DF
STT, self massage
what grading techniques ares used for mobilization of 1st MTP in extension?
grade 3 and 4
what strenghtning is suggested for plantar fasciopathy?
- hyperpronated foot: STR of intrinsic muscles of the foot
- might want to STR tibialis post and hip ABD/ER
exercise prescribed for plantar fasciopathy?
- pt raises the medial arch of the foot and asked to keep edge in contact w. groun and 1st MTP w/ toe resting normally on floor.
goa: 10 reps of 10s hold 4-5x per day
how can the biomechanics be corrected in the case of plantar fasciopathy?
- taping: only temorary while strengthening intrinsic muscles
- orthodics or new footwear
- othoses
what other Rx options are availible if consevrative Rx doesnt work for plantar fasciopathy?>
-corticosteroid injections for 4-6 weeks
high load STR exercise: HSR protocol
extracorporeal shockwave therapy
-surgery
what can be used to rule out ankle fx?
ottawa ankle rules
what is a grade 1 sprain?
-local tenderness
-microtear or overstretched
-minimal or no swelling
-lig stress test: no grap, normal EF, painful
POP over ligament
what is a grade 2 sprain?
macroscopic tear
marked POP over ligament
localized swelling/ bruised
lig stress test: gap, firm EF, pain
what is a grade 3 sprain?
complete rupture of ligament
+/- pain
swelling common, no tenmse effusion, fluid can circulate
lig stress test: gap ++, soft EF, may or may not have pain
which b/w MCL and LCL is more commonly ruptured?
LCL of the ankle since MCL is stronger, however rupture of MCL will take longer to heal
which ligament of the LCL of the anle is most commonly sprained?
ATFL since lease elastic component of the LCL
what is the sequence of ankle ligement sprain w/ inversion injury
ATFL > anterior capsule > distal anterior tibiofibular ligament > CFL > PTFL
how do LCL strains generally occur (MOI)
-inversion mechanis
what is the pain site of LCL sprain?
lateral aspect of the ankle/foot
what is the pain pattern of LCL sprain?
pain w/ inversion –> stretching of the ligament
what observations (swelling) can be observed in LCL sprains
2 patterns of swelling can be observed
- distal to lat malleoli: egg shaped occurs immediately after injury and generally associated w/ ATFL involvement
- swelling may spread to the foot when capsuleis torn of int. tibfib ligment is affected –> sandwhich like foot
what functional tests can be performed in a LCL sprain?
anatalig gait patterns/NWB
torsion test painful w/inversion
how is ROM of a foot w/ LCL sprain?
inversion and PF are painful
hypermobility due to ligament laxity
how is risom w/ LCL sprain?
depends on aaffected structure and pain level
how is proprioception w/ LCL sprain?>
decreased
what are possible Rx for LCL sprain to decrease pain and swelling
-PRICE/PEACE AND LOVE
-avoid heat
electrotherapy
-drainage/massage/ effleurage from distal to proximal
-light mobilizations; grade 1 and 2
what are possible Rx for LCL sprain to restore ROM
-NWB for the first 24h
-PWB until normal heel-toe pattern is obervsed
-AROM as soon as pain permits
DF in WB
-grade 3 and 4 mobilizations
what are possible Rx for LCL sprain to for STR
str in all directions
isometric then isotonic
what are possible Rx for LCL sprain to improve proprioception
5-10 moin/day 5x/week for 8-10 weeks unilateral eo --> ec stable to unstable surface double task
what are possible Rx for LCL sprain to return to functional exercise and activities
once pain free, full ROM and adequate str aand proprioception; ju,ps,. hops, figure of 8, stop and go
what is an anterolateral impingement generally secondary to?
an acute or recurrent ankle sprain in pf and inversion
where does anterolateral impingement generally occur?
ant. inf. tibiofibular lig
ATFL
anterior capsule
where is the pain site for anterolateral impingement
anterolateral side of the ankle
what is the pain type of anterolateral impingement
intermittent catching sensation
what is the pain pattern for anterolateral impingement
- pain present even once sprain has heeled
- pain increases w/ mvmt arom/prom for DF
how is ROM impacted in anterolateral impingement?
decreased DF in WB
catching sensation but no lig instability
can imaging be used for anterolateral impingement?
most reliable is MRI but not commonly used
how to treat anterolateral impingement?
conservative Rx
rest 4 weeks
use cast of splint to limit ankle ROM
ICE & NSAIDs for pain
what are the two locations for AT tendinopathy?
mid portion
insertional
what may be causes of midportion tendinopathy?
- weak plantar flexion
- increased df
- hypersupinated foot
- dec. knee flexor strenght
- poor tendon structure
how can weak PFs lead to mid portion AT tendinopathy?
failure to attenuater load = increased stress on tendon
how can increased DF rom lead to mid portion AT tendinopathy
increased loading periods thus more stress on tendon
how can hypersupination/ decreased DF rom lead to mid portion AT tendinopathy
shorter loading periods and as such same force distributed over shorter time thus decreased ability of tendon to absorb load
how can reduced knee flexor str lead to mid portion AT tendinopathy
gastroc may compensate and lead to over activation and thus increased stress on AT
how can Poor tendon structure lead to mid portion AT tendinopathy
less capacity to tolerate and absorb load
what type of organ is the insertional AT said to be?
enthesis organ
what may cause for insetional AT tendinopathy? what does this result in?
excessive DF w/ high tendile loads
compression/irrittation of the tendon and bursae leads to increased FC of tendon leading to assicifaction; haglund’s deformity
what are other pathologies associated w/ insertional AT tendinopathy?
retrocalcaneal bursitis
who is more at risk of insertional AT tendinopathy?
hypersupinated/ high rched feet
runners w/ important ms stiffness
pts w/ haglund’s deformity
what is important differential diagnosuis of insertional AT tendinopathy?
- achilles bursitis
- rheumatic conditions
how is the pain pattern in insertional AT tendinopathy?
pain w/ resistance of PF and DF stretch
how can a midportion AT be identified on observation?
if in reactive on degenerative phase; swollen, red, warm and thickened tendon
degenerative: thickening nodule
how can a insertional AT be identified on observation?
bursitis at the level of calcanues
haglunds deformity at calcneus
foot hypersupinated
how is the ROM for AT tendinopathy?
pain w/ AROM POF and EOR DF
pain w/ PROM DF EOR
when may pain be present w/ risom for AT tendinopathy?
w/ PF
how is the flexibility of gastroc and soleus w/ AT tendinopathy?
stiff and possibly painful
what tests (functional) can be done for assessing AT tendinopathy?
heel raise in WB
hopping
what may be a specific plapation associed w/ midpoint AT tendinopathy?
pain/thickening of fibers +/- nodules 2-6 cm above calcaneus
pinch test = +
what may be a specific plapation associed w/ insertional AT tendinopathy?
pain from bursitis of haglunds deformity
pain at calcaneus
whatb questionnaire is specific for AT
VISA A
is imaging needed to assess AT tendinopathy?
not needed but can be used to assess quality of tendon and bursae or info on bone (deformity)
what is the 4 stage program of Rx for midpoint tendinopathy
- isometric exercises
- isotonic of HSR exercises
- speed and energy storage exercises
- energy storage and release of sports specific exercises
what exercises are performed in stage 1 midpoint AT?
Seated w/ heel raises
Standing BW hold SLS vs DLS
Weight in standing heel raise machine
when can we progress to stage 2 for midpoint AT
when reactive pain has progressed
what protocol is used eccentric training in AT tendinopathy?
alfredson painful heel drop
how to train eccentric midportion AT?
begin on 2 legs and then go up- on unaffected side and then down on affected side
repeat 15 x leg straight, 15 x leg bent
how to train eccentric insertional AT?
ensure to stop mvmt at neutral DF
unaffected leg up, affected leg down
how to treat eccentrically if pain is bilateral
use a step to elevate one leg, the go on tippy toe of other and descend, process is to be repeated with other leg
how to treat AT tendinopathy using HSR
go from PF to neutral, only go lower in people who need STR in these angles
what should be trained before going to stage 3 for AT tendinopathy?
endurance
what stage should be continued lifelong 2x/week for AT tendinopathy?
stage 2
is additional loads added in stage 3 of AT tendinopathy?
no
how often is stage 3 for AT tendiopathy performed?>
EOD and on days it isnt performed, stage 2 exercises are performed
how does stage 4 for AT tendinopathy compare to stage 3?
exercises are done faster
how is pain monitored during exercises in rehab for AT tendinopathy?
use daily tests to assess pain levels
low load: SL heel raise
high load: hop
what happens if the isolated Rx for insertional AT is ineffective?
need to consider entire enthesis organ
how to treat for insertional AT tendinopathy
conservative Rx
- alfredson modified protocol w/ neutral DF
- heel raised 3-5 cm to reduce compressive loads
- avoid stretching
what are the presentations of a complete rupture of AT
macrotrauma rupture at midsection reports of snap/sound sudden pain feeling of being kicked at the back of the leg swelling limping generally cannot rise on toes (WB PF
where is pain felt in ruptured AT
at the AT
what should be looked out for in ruptured AT
- swelling/bruising
- antalgic gait pattern
- when in prone does the foot hang straight down off the edge of the bed
how is the strenght in ruptured AT
weakness of ankle in PF
what can be felt w/ palpation of a ruptured AT
gap of ~3-6cm
what test can be performed to assess for AT rupture
thompson’s test which involves squeezing the calf muscle and looking for sligh PF of the foot
is MRI/US used to diagnose ruptured AT
not all the time but can help confirm diagnosis
how can ruputred AT be treated
conservatively vs surgery
which procedure conservative vs surgery optimizes the STR of AT post rupture
surgical
which procedure conservative vs surgery has the risk of future rupture of ?
conservative
which procedure conservative vs surgery increases complications AT post rupture
surgery due to risk of infection
which procedure conservative vs surgery is generally done in which population
conservative generally done in older population
how to usse conservative Rx to treat ruptured AT tendon
cast or functional brace w/ crutches for 6-8 weeks
initially ankle in in max PF and then angle of PF decreases gradually
which b/w cast or functional brace seems to haver better results for conservative Rx of ruputred AT
functional brace
what mvmts may be permitted to pt using functional brace Rx for AT ruputre?
ROM on toes
light isometric PF
ankle ROM if brace allows
what is the protocol of Sx for AT rupture?
rehab begins ~6-8 weeks exercise in bracer, similar to conservative earliest mobilization possible WBAT ice, massages, US ROM: knee bent, restrict DF for ~6 wks STR: progressive stretching: only w/ ok from surgeon
what is the MOI for tibialis posterior tendinopathy?
overuse especially w/ subtalar overpronation
what is the painsite for tibialis posterior tendinopathy?
along the path of tib post. 3-4 cm before medial malleoli
when is pain w/ mvmt felt in tib post tendinopathy?
pain w/ AROM: PF and Inversion
pain w/ PROM for DF and eversion
how to treat tib post tendinopathy conservativedlu
-healing based on the stage of the teninopathy
initial progressive unloading then progressive loading exercises usingb the 4 stage program
STT as needed and mobiliation of TC of STjoints
MOI for tib ant tendinopathy?
overuse syndrome involving excessive DF or aassocied w/ footover pronation and stiffness of the TC or ST joint
pain site in tib anterior tendinopathy
along path of tib ant tendon
what can generally be observed in pts w/ tib ant tendinopathy?
hyperpronated foot
when is pain felt w/ mvmt in tib ant tendinopathy?
pain felt w/ arom in DF and inversion
PROM:
PF and eversion
how to treat conservatively tib ant tendinopathy?
same fashion as tib post tendinopathy
what is the MOI for gastroc ms strain?
microtrauma
max tension on gastroc when in lengthened position nd ms contracts
where is pain felt in gastroc ms strain?
medial belly
MTjunction
how to describe pain for gastroc ms strain?
acute, stabbing, tearing
how is pain w/ mvmt in gastroc strain?
arom: pain w/ PF and DF at EOR
PROM: pain w/ DF
note that low grades might not be painful
how is risom in gastroc strain?
pain w/ PF and extended knee
may be weak
what may be noticed w/ palpation of a acute gastroc strain?
warm if in substrate phase
pain at MT junction
may feel palpable defect –> grades 3
how to stretch gastroc?
soleus?
gaastroc: df w/ knee extended
soleus: df w/ knee flexed
what is a possible complication of gastroc strain?
DVT
what test is used to detect DVT
omen’s test
how to treat gastroc strain in the inflammatory phase
- police to decrease pain and swelling
-NWB
heel rise orthosis
how to treat gastroc strain in the proliferative
begin ankle and knee ROM exercise gentle gastroc stretch pain-free isometric exercises if pain free being str When pain free WB start proprioception
how to treat gastroc strain in the remodeling phase
gastroc stretch for flexibility
STR progression
functional exercises
DTF and STT as needed
when is Surgical Rx needed for gastroc Ms strain?
in cases of large ms disruption of failed conservative Rx after 6 months
