Ankle Pathology Flashcards
What age group does club feet (rigid equinas) affect?
peds
club foot leads to…
increased tone in plantar flexors and increased inversion
club foot may lead to this gate
toe walking
What joint should you measure ROM if you suspect club foot?
talocrural joint - patient may lose dorsiflexion because they spend too much time in plantarflexion
sever’s disease affect’s what age group?
adolescents (must be before the growth plate fuses)
What is severs disease?
apophysitis of the calcaneous at the achilles insertion
what do you find upon examination for severs disease?
- tender to palpate (achilles tendon insertion)
- pain with eccentric contractions
- often due to repetitive motion and overuse
What is the number one cause of ED visits?
ankle sprains because they fear a fracture
What is a differential diagnoses you want to rule out when you suspect an ankle sprain?
ankle fracture
What joint is involved with ankle sprains?
talocrural joint
What ligaments are involved in a high ankle sprain?
- interosseous membrane
- anterior tib-fib
- posterior tib-fib
What MOI would make you suspect a high ankle sprain?
ER and dorsiflexion of foot MOI
What is the most common ankle sprain? the least?
lateral, medial
What ligaments are involved in a medial ankle sprain?
Deltoid lig:
- ant tibio-talar
- tibio-navicular
- calcaneo - tibio
- post tibio-talar
What MOI causes a medial ankle sprain?
moment of eversion
What MOI causes a lateral ankle sprain?
moment of inversion
What is the most commonly sprained ankle ligament?
Anterior talo-fibular (ATF)
What are the 3 ligaments involved in a lateral ankle sprain?
- anterior talo-fibular (ATF)
- calcaneo- fibular
- posterior talo-fibular
What causes a subtalar joint ankle sprain?
significant trauma like a car accident, much less common, very problematic
What ligaments are involved in a subtalar joint ankle sprain?
- interosseous talo-calcaneal
- cervical ligament
What are key point in these portions of an eval?
1 - subjective
2 - visual observation
3 - ROM
4 - Palpation
5 - special tests
1 - MOI is #1!
2 - should see swelling or bruising
3 - will probably lose ROM because you’re guarding ankle
4 - find certain ligs
5 - only really used for chronic ankle sprain issues
What are the 2 classification systems for ankle sprains?
1 - functional
– grade 1 to 3 based on instability
2 - ligament
grade 1: ATF
grade 2: calcaneo-fib
grade 3: post talo-fib
What are two special tests for lateral ankle sprains?
anterior drawer test
inversion stress test
Why do we use xrays with an inversion stress test?
use degree measurement to gage amount of instability/# of ligs involved
ottowa ankle rules
- over 55
- can’t do more than 4 steps
- post edge/tip of lateral malleolus tender
- base of 5th metacarpal tender
- navicular tenderness
- post edge/tip of medial malleolus tender
What are 3 xray views we use to differentiate ankle fractures with ankle sprains?
- anterioposterior view
- mortise view of ankle
- lateral view of ankle
What does the anterioposterior xray view tell us
- general shape/postition/texture
- medial talus/tibia (2-3 cm wide)
- lateral talus/tibia (6mm overlap)
What does the mortise view of the ankle tell us?
the lower leg and foot IR 15-20 degrees (to move fibula out of the way = better view of the talus)
What does the lateral view xray tell us?
can look at the calcaneus and the achilles tendon
If you cannot see the Kager’s triangle in the lateral view of an ankle xray what does that mean?
there is an injury to the achilles tendon
Why would you rather have a CT scan than an xray?
its the go to for bony pathology at the ankle (could see posterior malleolar fracture better in slides)
What xray views would you want to see for a foot fracture?
- dorsoplantar
- medial oblique view of foot
what does the dorsoplantar view of the foot tell us?
shows the forefoot/midfoot joint
What does the medial oblique view of the foot show us?
tarsals/metatarsals
What imaging is best to see a stress fracture at the ankle or foot?
MRI
Other than a fracture, what other differential diagnosis at the ankle would you want to rule out?
articular cartilage injury (will complain of catching or locking, can happen on the talus or tibial plafond)
What are 3 general lower leg pathologies you want to be on the lookout for?
- medial tibial stress syndrome
- chronic compartment syndrome
- tendinopathy
medial tibial stress syndrome is also known as…
shin splints
What are the two ways to grade shin splints?
functional or bony
describe the functional grades of injury for shin splints
1 - pain occurring after activity
2 - before, during and after activity not affecting performance
3 - before, during, and after affecting performance
4 - pain so severe performance is impossible
describe the bony grades of injury for shin splints
0 - normal bony remodeling
1-3 - mild, mod, or severe stress reaction
4 - stress fracture
What are some exam findings that have been found to contribute to shin splints/stress fractures
- greater pelvic tilt excursion
- peak hip IR (pronation)
- decreased knee flexion (land too stiff)
- greater hip adduction (IR and over pronation)
- greater rearfoot eversion (over pronation)
- females at greater risk (Q angle)
- pronated foot type (overload tibia)
- varus load
- cumulative load
What are some biomechanical factors associated with medial tibial stress syndrome
- higher standing tibia varus angle
- reduced static dorsiflexion
- more rearfoot eversion at heel-off
- longer duration of eversion during stance
What are the lower leg compartments
- anterior
- post (deep/superficial)
- lateral
What factors should you include in your exam when concerned about compartment syndrome?
- motor
- sensory
- vascular
Where are we concerned about tendinopathy in the lower leg?
- achilles (most common)
- posterior tib
- peroneal (fib) tendons
- anterior tib (least common)
What are the 2 pathologies for achilles tendinopathy
mid-substance and insertional
What are the two etiology factors for achilles tendinopathy
- intrinsic vs extrensic (fluoroquinolones)
- anatomical (degenerative/biomechanical)
What will you find upon exam/diagnosis for achilles tendinopathy?
- with resisted and passive testing plantar flexion is weak
- palpation on the tendon will be painful
Loss of ________ leads to planar fascitis
dorsiflexion
What are the possible structures involved in plantar fascitis
plantar fascia, heel pad, medial > lateral plantar nerves
What is the most common cause of heel pain?
plantar fasciopathy
> 80% of patients experience resolution of plantar fascitis in 12 months regardless of ______-
treatment
What are risk factors of plantar fasciopathy
- high BMI
- running, work related weight-bearing
- limited dorsiflexion
symptoms of plantar fasciopathy
pain after prolonged inactivity
- improves with activity
- often increases late in the day
- stretching plantar fascia makes it feel better
- palpation of plantar fascia is painful
When examining plantar fascia you must look at these joints for ROM/position
- talocrural joint (dorsiflexion)
- 1st MPT - (extension through big toe)
- subtalar joint and midtarsal joint position (evert too much loads fascia more)
- 1st ray mobility (transfer of force issue)
hallux valgus bony structure involves…
prox phalange, 1st metatarsal, 2nd metatarsal, medial/lat sesamoids, 1st MPT joint congruency
What ligaments are involved in hallux valgus
- synovial capsule
- collateral lig
- fibrous plantar plate
- lisfranc’s lig
What are some etiology risks for hallux valgus
family history (#1), females, foot shape (narrow heel, wide forefoot, long/short 1st metatarsal), foot wear (too narrow or loads forefoot), RA, Pes planus, LOSS OF ANKLE DORSIFLEXION
What do you want to examine for hallux valgus
- medial longitudinal arch height
- 1st MPT joint angle
- gait
will always want to palpate too
What ROM considerations do you have for hallux valgus
- ankle dorsiflexion
- 1st ray mobility
- 1st MTP joint
definition of metatarsalgia
- irritation of the bone and soft tissue around metatarsal head
- more common at 2-4th metatarsals because being over pronated loads middle metatarsals more
etiology of metatarsalgia
- over pronation
- tight gastroc/soleus (probs weak)
- activities that facilitate forefoot weight bearing like sports and high heels
What do you want to rule out with palpation for metatarsalgia
stress fractures, other comorbidities and risk factors
What is one geriatric concern we have at the ankle?
OA
_________ is key!
palpation
