Foot and Ankle 2 (test 4) Flashcards
prevalence of achilles tendinopathy
most frequent overuse injury
10-20% of runners
most common in recreational activities, training > competition
30-50 yr olds
risk factors/etiology of achilles tendinopathy
reduced DF ROM (limit PE of achilles)
limited calf flexibility
calf weakness
possible L4-S1 regional interdependence
male gender/family hx
abnormal tendon structure
older age
obesity
systemic conditions with inflammation/limited blood supply
training errors/environment/improper shoes
how might L4-S1 regional interdependence cause achilles tendinopathy
excessive EV/pronaiton with tendinopathy origins b/c achilles attaches more medially
hip neuromuscular deficits
balance deficits
pathomechanics of achilles tendinopathy
repetitive lengthening with compression from limited DF and/or excessive EV
lack of PE with limited DF so overworked
collagen fibril thinning/disorganization and fibroblast death from altered fluid movement that leads to heating and increased nitric acid with persistent inflammation
ineffective force transfer
impaired motor control
thickened but weaker tendon from increase of non-collagen matrix and fat deposition
functional questionaires for achilles tendinopathy
victorian institue of sport assessment
foot and ankle ability measure
LEFS
symptoms of achilles tendinopathy
gradual onset that limts WBing activity
localized pain and stiffness
-especially after inactivity
-lessed with mild activity
-increase with mod to severe activity
observation of achilles tendinopathy
achilles thickening
possible imaired LE control
ROM findings for achilles tendinopathy
pain and limits with DF
resisted/MMT findings for achilles tendinopathy
pain with PF possible; maybe weak
possible hip and knee weakness
AM findings for achilles tendinopathy
possible talar hypomobility for DF
special tests for achilles tendinopathy
arc sign
royal london test
single leg heel raise
-flat surface vs incline (plataris and insertional injury if more pain on incline
-for PF endurance = less reps vs uninvolved
single leg hop = less reps than uninvolved
M. length shortened gastroc
palpation findings for achilles tendinopathy
TTP 2-6 cm proximal to insertion
more medial achilles pain indicates plataris
achilles crepitus
differential dx at posterior ankle
achilles/fascial tears
calcaneal bursitis
plataris tendinopathy
posterior ankle impingement
sural neuritis
acessory soleus muscle
achilles ossification or talar bone spur
inflammatory dz
pt edu for achilles tendinopathy
rest is NOT indicated
optimal stess is best within appropriate pain levels = mild pain
wt management
shoe wear
timeline = 8-12 wks; at least 6
prognosis = 80% improvement if both pt and PT are doing the right things
modalities and their effectiveness for achilles tendinopathy
LASER = contradictory evidence
iontophoresis = dexamethasone helpful for pain and function
shockwave
-support for pain relief with ADLs when added to 4 wks exercise
-no indication on structure change or return to sport
bracing support for achilles tendinopathy
neoprene sleevs on involved muscles only anecdotal
night spint NOT beneficial and NO support
taping support for achilles tendinopathy
anecdotal and conflicting evidence
arch taping/foot orthotics support for achilles tendinopathy
taping may help predict orthotic benefit
shock absorbing orthotic decreased injury rate
heel lift = mixed support; needs to happen on both sides
dry needling support for achilles tendinopathy
helful for pain when added to exercise
questionable otherwise
STM support for achilles tendinopathy
mostly anecdotal
ASTYM helpful for motion when added to exercise
gentle stretching support for achilles tendinopathy
weak but some support for pain
may be contraindicated due to higher tension/compression on tendon
JMs serve what purpose for achilles tendinopathy
mobility and function
what MET has best evidence for achilles tendinopathy
varied muscle actions
eccentrics only = alfredson protocol
heavy and slow eccentrics
isometrics
lower compliance rates with eccentric training
ultimate MET parameters
3 sets 10-15 reps
3 sec phases of muscle actions
heavy load - NOT during inflammatory phase
how should you progress MET for achilles tendinopathy
progress resistance and activity with less than or equal to mild symptoms
can add weight via backpack, use heel raise machine, or do sitting/standing heel raises
how long should achilles tendinopathy be treated
at least 2x/week for 6 weeks
recommended to do every other day
may need more recovery time between loading in older/non-athletic pt (about 72 hours)
repeat exercises once normal pain levels return
recurrence rate for achilles tendinopathy
27%
success rates for achilles tendinopathy
mostly normalized tendon structure and thickness
improved mechanical properties as well as cortical structures
about 12 weeks to recovery
80% fully recovered within 3-6 months of progressive loading at 5 year follow up
success rates for eccentric exercuses
82-100% mid portion tendinopathy in athletes
60% sedentary individuals
less than 32% insertional tendinopathies
what % of people have mild pain remaining with achilles tendinopathy
20-45%
effect of injections for achilles tendinopathy in mid portion vs insertional
midportion
-insufficient evidence for cortisone
-emergign evidence for high volume injection/scleroptherapy
insertional = guided cortisone is effective for pain and function
-alternate option when MET isnt working
-recommended for non-athletic population
MD Rx for achilles tendinopathy
injections
achilles debridement
remove plantaris
prevalence and etiology of calcaneal apophysitis
aka Sever’s disease
9-12 years old most common
males > females
etiology = growth with high activity
structure/pathomechanics for calcaneal apophysitis
leg bone growth exceeds PF lengthening
increased tendon tension
growth plate is the weak spot as opposed to tendon in the adult
mostly inflammation
complcations = avulsion/premature closure
risk factors for calcaneal apophysitis
long or year round sports
poor fitting shoes that lack cushion
training errors
shortened PFs
foot dysfunction (i.e. pes planus/cavus)
symptoms of calcaneal apophysitis
gradual onset of heel pain with overuse
Bilateral more than unilateral
pop = avulsion
observation for calcaneal apophysitis
poor shoe/support cushion
foot dysfunction (i.e. foot pronation or supination)
impaired LE control
ROM findings for sever’s
limited DF leading to greater tensile forces on growth plate
resisted/MMT findings for severes
possible weak and painful PFs
weak DFs
special tests for calcaneal apophysitis
squeeze test on heel
severe’s sign = pain with heel raise
M. length = short gastroc
palpation findings for severe’s
TTP over “cap” of calcaneus
PT Rx for calcaneal apophysitis
pt edu:
-soreness rule
-load management
-movement cues for LE control
POLICED
“U” shaped foam upside down on achilles with ankle sleeve
restore DF ROM/accessory motion
-JM and STM
-careful with prolonged calf stretch
hamstring stretch due to fasical connection with gastroc
orthotics effectiveness for calcaneal apophysitis
arch support for excessive pronation
heel lifts
heel lifts > arch support
-more effective at 2 months
-equally effective at 12 months
gel heel cups with a lift work best
MET for calcaneal apophysistis
for any impaired LQ control
caution with muscle/tendon attached to growth plate to avoid greater overuse
prognosis for calcaneal apophysitis
75% resolved at 1 month and 95% at 3 months
can be a recurrent and or persistent problem
growth plate closes around 14 years
what is plantar fasciopathy
heel pain
most common foot condtion
clear risk factors for plantar fasciopathy
increased PF ROM (ankle instability)
High BMI
running/ work related WBing with poor shock absorption
impaired 1st MTP ext that reduces PE of fascia
older age
unclear risk factors for plantars fasciopathy
decreased DF that limits PE of fascia
tendinopathy origins (excessive dynamic pornation and standing calcaneal EV)
describe the structure of the plantar fascia
3 bands (medial, central and lateral)
central originates on medial tubercle
inserts in all proximal phalanges
assists with gait via windlass effect that is PE developed by normal foot and ankle motion
structures involved with plantar fasciopathy
intrinsic foot muscles
heel fat pad innervated by tibial n
achilles tendon fibers connect with plantar fascia
medial and lateral plantar nn
bone spurs (plantar fascia thickening and fat pad thinning were better indicators)
etiology and pathomechanics of plantars fasciopathy
primarily = structural changes (54%)
only inflammation = ~20%
neoplastic (connective tissue tumor) = 25%
functional questionaires for plantars fasciopathy
foot and ankle ability measure (FAAM)
foot health status questionnaire (FHSQ)
foot function index (FFI)
lower extremity functional scale (LEFS)
symptoms of plantars fasciopathy
gradual onset of heel pain after recent increase in WBIng activity
medial > central heel pain
-after long periods of inactivity
-worse at end of day/prolonged WBing
-can improve with mild/mod activity
observation for those with plantar fasciopathy
thickened plantar fascia
possible static calcaneal EV
possible asymmetrical and antalgic gait
possible excessive dynamic pronation
possible impaired LQ control
ROM findings for plantar fasciopathy
limited 1st MTP ext
resisted/MMT findings for plantar fasciopathy
possible weak and painful toe flexors
special tests for plantar fasciopathy
lack of plantar flexion tautness
palpation findings for plantars fasciopathy
TTP over medial calcaneal insertion > central heel pain
other differential dx for plantar fasciopathy/heel pain
spondyloarthropathies or autoimmune conditions
calcaneal stress fx
bone bruise
fat pad atrophy
tarsal tunnel syndrome
fibrous tumor
calcaneal apophysitis
radiculopathy
PT Rx for plantar fasciopathy aside from MET and MT
pt edu
-sireness rule
-load management
-movement cues
-wt. loss
-cushioned surfaces with long standing
POLICED
modalities
-short term relief with ionophoresis + dexamethasone or acetic acid
-short term relief with LASER + ponophoresis
-shockwave = NOT more effective than stretching or US; possible adverse affects
US/electrotherapy not recommended
taping = short term relief only
orthotics
-better for those who benefited from taping
-benefits for persistent type
dry needling NOT RECOMMENDED
manual therapy for plantar fasciopathy
goal = normalize mobility and m lengths for pian, ROM, and function
JM = mixed benefits
-improves pain and function along with orthoses and MET
-helpful but not additive to stretching
-imporve DF and 1st MTP ext
stretching calf & plantar fascia
-calf stretch alone = no difference with DF and pain
-both improved pain but more reduction with fascia stretch
JM + STM
-deep massage to gastroc and fascia
-rear foot JMs
what shoe characteristics may help those with plantar fasciopathy
-shoe rotation = dont wear the same ones all the time
-rocker bottom shoe =
how is the static standing method of choosing footwear concerning
overly simplistic
potential injury
problematic for those with excess pronation
doesnt represent dynamic foot
effectiveness of night splint
wear for 1-3 months
improved impaired DF due to shortened PFs
hard to get pts to comply
MET for plantar fascipathy
primarily for fascia proliferation
tendinosis Rx (like achilles but + hyperextension of toe)
pronation control exercises (especially tibialis post and other LE muscles that can contribute to impaired LE control)
prognosis for plantar fasciopathy
80% resolution of symptoms
