CBL Sports Med Flashcards
Main ankle joints
Tibiotalar joint (true ankle joint) - responsible for plantar and dorsi flexion
Talocalcaneal or subtalar (false ankle joint)
- responsible for inversion and eversion as well as shock absorption
Too man toes sign
3+ toes can be seen when looking at a resting patient from the posterior
Often a result of pes planus
Most stable position of tibiotalar joint
Dorsiflexion
- superior dome of talus is wider anteriorly cause more contact with ankle mortise when rocking backward in dorsiflexion= better stability
Least stable position of tibiotalar joint
Plantar flexion
- superior dome of talus is more narrow posteriorly and makes less contact with the ankle Mortise when rocking forward and anteriorly during plantar flexion = less stable
Sprain vs strain
Sprain = abnormal stretch/tearing of a ligament
Strain = abnormal stretch/ tearing of a muscle or tendon
Why are inversion sprains more common than eversion?
Medial ligaments are stronger than lateral ligaments
In inversion, ankle is plantar flexed which is unstable
Grade 1 ankle sprain
Stretching or microscopic tearing of the anterior talofibular or calcaneofibular ligaments (usually)
Caused by forced inversion and plantar flexion
Clinical presentation:
- mild tenderness and swelling
- little or no function loss
- minimal pain
- no mechanical instability of ankle
Grade 2 ankle sprain
Partial or complete tear of the talofibular ligament and stretching of the calcaneofibular ligament
Clinical presentation:
- moderate tenderness and swelling
- moderate ecchymoses (brushing)
- tenderness when palpating
- some motion and function loss
- pain when weight bearing
- mild-moderate instability of ankle
Grade 3 ankle sprain
Complete Tears of both the anterior talofibular and calcaneofibular ligaments
Partial tears of the posterior talofibular ligament and tibiofibular ligament
Clinical presentation:
- severe tenderness and swelling
- severe ecchymoses (bruising)
- strong tenderness when palpation of the ligaments and surrounding structures
- loss of function and motion
- serious mechanical instability of ankle
Anterior drawer and Tamar tilt tests
Anterior drawer test: slight plantar flexion of ankle with cephalad hand stabilizing distal lower leg
Caudad hand translates foot forward from calcaneus
(+) =. More than 5-8 mm compared to uninsured ankle
Talar tilt test; slight plantar flexion of ankle with one hand stabilizing the distal tibia just proximal to the medial malleolus. Other hand applies a slow inversion force with palpation at the lateral talus.
(+) = more more than 10 degrees compared to uninsured side
Grade 1 sprain: (-) on both
Grade 2 sprain: (+) on anterior drawer test, (+) or equal on talar tilt test
Grade 3 sprain: (+) on both
Treatment of ankle sprains
- RICE and NSAIDs or acetaminophen when needed
- OMT can be used as long as its indicated
- PT should be started as soon as tolerated
Usually no surgery on lateral ankle sprains/strains however, can be done with medial ankle sprains/strains
Can use Velcro brace and/or walking boots when needed for support
High ankle sprains/syndesmoses injuries
Usually results from tearing the following
- anterior inferior tibiofibular ligament
- Posterior inferior tibiofibular ligament
- interosseous membrane
Clinical presentation:
- no fracture: pain with dorsiflexion
- w/ fracture: cant put weight on it
3 phases of treatment in high ankle sprain conservative treatment
- RICE and NSAID’s when needed in all phases*
1st: non-weight bearing wearing a boot for 5-7 days and passive ROM exercise without booth 3 times a day
2nd: wearing weight baring brace for as long as pain is present while hopping . Use gait and light proprioceptive exercises
3rd: once no plain on foot and ankle with hopping. Protected full-weight baring (usually like a wrap) start resistive exercise and multi-axial ankle movements
Perineal muscle strains and factors that increase likelihood of occurring
Muscle strains in the lateral ankle via an eversion ankle sprain
Predisposed factors:
- prior ankle injuries
- respected inversion ankle injuries
- pes planus
- walking w/ excessive eversion for whatever reason
- poor fitting athletic equipment
Clinical presentation:
- pain and swelling along lateral ankle
- feeling of weakness or instability
- snapping sensation along lateral malleolus if retinaculum is torn
Muscle tendons in the medial ankle
Tibialis posterior tendon (Most common one injured during medial ankle sprain)
Flexor digitorum longus tendon
Flexor hallucis longus tendon
Factors that lead to tibialis posterior muscle strains
Over use
High impact sports
People older than 40 yrs
Obesity
Acute injury
Clinical presentation:
- pain along medial foot and ankle (worsens w/ activity and standing for prolonged time)
- swelling along medial foot
- pes planus (sprains cause longitudinal arch to drop, leads to lateral foot pain)
Testing for tibialis posterior muscle sprain and treatment
Stand on one leg and raise the heel of the stance leg.
(+) patient cant do this
- overall limited flexibility especially dorsiflexion
Treatment =
- RICE, acetaminophen and low impact exercises.
- PT and arch support as well
Medial ankle muscle tendons
Tibialis anterior tendon (most commonly injuried)
Extensor digitorum longus tendon
Extensor hallucis longus tendon
Factors that lead to increase likelihood of tibialis anterior muscle strains
Overuse
High-impact sports
Running or jumping on hard surfaces repeatedly
Acute injury
Pes cavus
Clinical presentation:
- pain along anterior-lateral tibia and dorsum of foot
- swelling anterior-laterally
- pain that worsens w/ activity and walking
- dorsiflexion weakness
Plantar fasciitis
Pain located at the anterior portion of the calcaneus in the plantar foot along the aponeruosis
Causes:
- obesity
- pregnancy
- long distance runners w/ tight calf’s
- prolonged time standing on feet
- being bare foot a lot
- more common in older than 40 and female
Plantar fasciitis clinical presentation and treatment
Clinical presentation:
- pain worse in morning or after prolonged inactivity. Pain will improve after walking
- pain worsens when climbing stairs
- flares with prolonged activity
Treatment:
- RICE
- stretching of gastrocnemius/ plantar fascia
- orthotics
- steroid injections
- OMT or PT
Achilles’ tendon rupture
Loud audible pop after experiencing Achilles tendonitis.
- most often ruptures at the “watershed” area of the tendon (4-5 cm proximal to calcaneus)
Ottawa ankle rules
Rules for getting an xray for the ankle
1) ankle pain in the malleolar zone compoundered with one of 2-4
2) bone tenderness along distal 6 cm of posterior fibular or the tip of the lateral malleolus
3) bone tenderness along the distal 6 cm of posterior tibia or the tip of the medial malleolus
4) inability to bear weight w/ 4 steps immediately after injury and at the office
Ottawa foot rules
Rules for getting a foot x ray
1) foot pain in the mid-foot zone and one of 2-4
2) bone tenderness at the base of the 5th metatarsal
3) bone tenderness at the base of the navicular bone
4) inability to bear weight w/ 4 steps immediately after injury and in the office
