Foot and Ankle 3 (test 4) Flashcards
structures involved in shin splints
anterior = anterior tibialis and lateral tibial shafted
posterior or medial tibial stress syndrome = tibialis posterior and medial tibial shaft
posterior more common (4-19% athletes)
periosteum
-connective tissue that surrounds bone except articular surfaces
-most densly innervated tissue
risk factors for medial tibial stress syndrome (MTSS)
female
high BMI
previous running injury
excessive pronation (increased navicular drop; primarily controlled by tibialis posterior)
increased PF ROM (unclear why)
greater hip ER (not understood)
no meaningful association with shoes
pathomechanics of MTSS
increased load on tibialis posterior leading to subsequent tension and inflammation of periosteal tissue
symptoms of MTSS
gradualonset medial shin pain
generally worsened with exercise and not ADLs
no cramping/burning/tingling
1/3 have coexisting leg injuries
observation of those with shin splints
overstriding leading to greater heel strike
impaired LE control
-excess pronation
-increased pelvic drop
-increased LE IR
resisted/MMT findings for MTSS
weak and possibly painful PFs
limited hip ext/abd strength and endurance
possibly weak and painful IV
special tests for MTSS
pain with hop on ball of foot due to plantar flexion of tibialis posterior
possible foot and or ankle instability
palpation findings for MTSS
TTP over posterior medial tibial border >5cm or 2 in in length
PT Rx for MTSS aside from MET and MT
POLICED
pt edu
taping/orthotics
specific edu for MTSS
movement pattern training
-not changed by strength alone
-reduced LE IR
-decreased heel strike + cue for shorter/faster steps
shoe wear
-light/supportive/cushioned
-rotate shoes
-change running shoes every 250-500 miles
purpose/effectiveness of taping/orthotics for MTSS
taping to assist tibialis posterior
foot orthotic for
-excess pronation
-heavy heel strikers
air cast for functional support that allows ankle motion
walking boot in severe cases
MET and MT for MTSS
MT for any joint dysfunction like limited DF
MET primary focus = unloading tibia and tibialis post
hip ER/EXT/ABD
improve PF and IV strength
-soleus supports 8x BW
-gastroc/soleus counters distal tibia bending
-tibialis posterior is primary invertor
address spinal stabilization as needed
differential dx for medial tibial stress syndrome
bone stress injuries of tibia
-stress reaction (periosteal and/or marrow inflammation)
-stress fx (cortical break)
compartment syndrome
bones stress prevalence/incidience
females > males
common in adolescent (specifically early HS age)
tibia most common bone
most common in people who dont let body rest (6-7 days/ wk sports participation)
common in runners
common bones for stress injuries
tibia = most common in runners
fibula = distal most common
metatarsals
-base of 5th most common; prone to avulsion
what are the 3 zones of injury for metatarsals
zone 1 = 90% of fxs and mostly with sprains
zone 2 = most susceptible to AVN
zone 3 = typically from repetitive stress
risk factors for bone stress injury
high forces
impaired LE control
longer stride
greater heel strike
repetitive jumping/walking
weakness
lack of recovery from training
high training load
pathogenesis of bone stress injuries
increased loads and frequency w/o recovery
osteoclastic activity exceeds osteoblastic activity
symptoms of bone stress injuries
generally worse pain eith ADLs and exercise and may become constant
signs of bone stress injuries
typical fx S&S
bone pain reproduced with hop test
imaging
-radiograph = may not show for 2-6 weeks
-MRI = gold standard; doesnt refelct healing
PR Rx for bone stress injuries (lifestyle changes)
adress diet and hormonal limits due to possibly decreased bone density
-meet energy expenditure
-Vit D
-Calcium
-regular menstrual cycle
well managed sleep/stress/BMI
meds = antacids prevent gut absorption of calcium
important facts related to bone stress injuries
adolescent bone doesnt equal adult bone
bone density decreases before growth spurt and takes up to 4 years after to increase
average growth spurt = 11.9 female and 13.6 males
average menarche = 12 years
SO WHAT = there is a period of skeletal weakness after a growth spurt especially with females who are also dealing with hormonal and skeletal changes and greater affects on BMD and muscle strength
load management rx for bone stress injury
graded unloading to ambulate without pain
gradual and progressive return to activity while addressing risk factors and etiologies
prognosis for tibial stress fx
BMD lowest at 3 mothts post fx in BOTH legs
BMD returned to baseline between 3-6 months
reinjury to either is likely prior to 3 months
all were at bseline BMD at 6 months, surpassed at 12 months
etiology of compartment syndrome
Blunt trauma
overuse
pathogenesis of compartment syndrome
increased swelling with limited fascial extensibility
compression of neurovascular structures in the anterior leg compartment
S&S of compartment syndrome
recent blunt trauma or overuse to anterior compartment
cramping/burning/tingling
lengthening/use of DFs adds compression/P!
possibly weak DF
S&S of compartment syndrome
pain
palpable tenderness
pulselessness
pallor - balancing
paraesthesias
paralysis
Rx for compartment syndrome
unrelenting 6 Ps = medical emergency due to neurovascular compromise and need for surgical fasciotomy to prevent tisse death
modifiable 6 Ps = PT directed at source of inflammation and fascial extensibility; sx may be necessary
what is a Pott’s fx
ankle fx
bi-malleolar = distal fibula + distal tibia
tri malleolar = tibia + fibula + posterior tibial rim
prevalence of fxs in rear, mid, and forefoot fx
rear = calcaneus = most common
mid = rare except for navicular
fore = most common region of fx
most common foot joint that deals with ARJC and why
1st MTP
in WBing:
-2x the load of lesser toes
-40-60% of BW
-1-2x BW with sports
gets rigid for propulsion with greatest forces from just before heel off to toe off
etiology of ARJC in the foot
longer 1st ray
trauma
genetic
symptoms of ARJC in foot
gradual onset
AM stiffness < 30 min
dorsal joint P!
antalgic/asymmetrical gait
observation of ARJC in foot
hallux valgus
possible excessive pronation (greater load on 1st ray)
claw toe = MTP hyperext + IP flex
hammer toe = MTP hyperext + PIP flex + DIP hyperext
mallet toe = neutral MTP and PIP with flexed DIP
dorsal sput at 1st MTP
gait issues/poor LE control
ROM for ARJC at the foot
capsular pattern for great toe = loss of ext > abd (hallux limitus/rigidus)
combined motion, stress tests, and AM for ARJC at foot
consistent block
possible + for compression/distx
AM = hypomobile 1st MTP, DF, and/or sesamoid bones
PT Rx for foot ARJC outside of MT and MET
POLICED
proper footwear to unload cartilage and accomodate for deformaties/impaired biomechanics
assistive devices
MT for ARJC at foot
most effective early on or with younger pts
applied to MTP, sesamoids, and ankles
MET for ARJC at foot
tissue integrity/mobility
address any LE control contributing to excessive pronation
MD RX for ARJC at foot
injections = poor evidence; don’t use
sx
- past = bone excision and fusion
-newer = lapiplasty = 3D correction.of dysfunction through the midfoot to better address causative excessive pronation
what is morton’s neuritis/-oma
compression of interdigital nn
acute inflammatory = neuritis
chronic fibrous cyst = neuroma
etiology of mortons neuritis/-oma
excessive pronation
small toe boxes with/without heels
limited 1st MTP ext shifts load to lateral foot
pathomechanics of morton’s neuritis
excessive pronation leading to excessive intermetatarsal compression
what is tarsal tunnel syndrome
aka posterior tibial neuralgia
entrapment of tibial n at flexor retinaculum/medial malleolus
etiology/pathomechanics of tarsal tunnel
excessive pronation leading to excessive tension and compression of tibial n
nerve compression rx
POLI-ED (NO C)
JM/orthotic/MET to reduce compresison by assisting with abnormal mechanics
MET also to create neural motion/flossing
