Foot and ankle overuse/running injuries

Question 1

internal factors that can cause overuse injuries in the foot and ankle

Answer 1

• abnormal bony structure alignment: pes cavis foot, tibial torsion, leg length etc
• abnormal biomechanics or foot and ankle: pronation, supination, exercise, mobility, orthotics etc
• Muscle imbalances: weakness/tightness

Question 2

External factors that can cause overuse injuries in the foot and ankle

Answer 2

• faulty training
• overzealous training
• improper footwear
• ground surface/terrain

Question 3

How does overuse injuries relate to physiological tissue stress

Answer 3

• results of repetitive sub-traumatic forces (often w/o recovery)
• microtrauma to tissue exceeds rate of repair
• inadequate recovery time
• pathophysiology: inflammatory response in tissues
• can alter tissue: fatigue, weakness, atrophy, fat infiltration, tissue breakdown

Question 4

Physical stress theory - excessive stress on tissues
- tendon
- ligament
- muscule
- bone

Answer 4

• tendon: tendonitis → tendinosis → tendon tear → rupture
• ligament: sprain → tear ligament fibers → full tear
• muscle: strain → muscle fiber tear → complete tear
• bone: stress fractures → fx

Question 5

running injuries occur as a result of

Answer 5

• higher stress during short period of time (sprinting)
• milder abnormal stresses for longer periods
• an abrupt increase in activity level

Question 6

Excessive pronation or late pronation can causes what?

Answer 6

• lack supination = decreased stability of foot in terminal stance
• pronation stresses to foot/ankle
• plantar fasciitis, tarsal tunnel syndrome
• overuse of anterior tibialis, posterior tibialis, FD and FHL tendons - eccentrically trying to control pronation

Question 7

What can also contribute to excessive or late pronation

Answer 7

• excessive Hip IR, adduction (adductor collapse)
• valgus stress at knee
• MCL tensile stress, compression at lateral knee

Question 8

Supinated foot/pes cavis cancause what

Answer 8

• less shock absorption → increase forces on bones → stress fx
• tensile stress on lateral ankle → muscles and ligaments
• prone to lateral ankle sprains

Question 9

structural leg length discrepancy compensation causes

Answer 9

• supination on short leg (makes it functionally longer) and problems with supinated foot
• pronated on long leg to functionally shorten it + problems associated with pronation stresses

Question 10

What are abnormal structural factors that can result in excessive stress on tissues

Answer 10

• supinated foot/pes cavis
• structural leg length
• tibial torsion

Question 11

Lateral tibial torsion

Answer 11

• too many toes sign
• stress gets put on medial side leading to pronation and stress
• normal = 15 degress of ER

Question 12

Musucle imbalances factors reatedto stress on tissues examples

Answer 12

• weak hip ER, and abductors
• tight gastroc-soleus and weak a pre-tibial

Question 13

Weak hip ERs and abductors

Answer 13

• allows femoral adduction/IR collapse
• knee stresses: genu valgum, MCL, PFJ (maltracking of patella)

Question 14

Tight gastroc-soleus and weak pre-tibial muscules

Answer 14

• anterior tibialis, EHL, ED have to work harder
• associated with anterior shin splints especially with hill running
• uphill– pretibial muscles work excessively to clear ground - also stress Achilles
• downhill: pre-tibial muscles work excessively eccentrically after heel strike to lower foot

Question 15

Shin splints

Answer 15

• catch all term
• pain and inflammation at: bone insertional sites, tendon, musculotendinous junction of lower leg muscles, muscle belly
• anterior, posterior, or lateral compartments
• overuse, recovery, terrain, abnormal biomechanics

Question 15

tenosynovitis + S&S

Answer 15

• inflammation synovial tendon sheath
• Swelling, pain, crepitis

Question 16

common tendons involved with tenosynovitis (over pronators vs supinated foot)

Answer 16

• over pronation: medially posterior tib, FDL, FHL, anterior tib (increased tensile stress eccentrically to control pronation)
• Supinated foot: peroneus longus and brevis (subjected to tensile stress)

Question 16

Posteromedial shin splints

Answer 16

• muscules: tibialis posterior, FDL, FHL
• excessive pronation stress
• posterior medial musculature

Question 17

Anterolateral shin splints

Answer 17

• Tibialis anterior ED, EHL
• eccentric control of foot at heel strike

OR

• concentric: swing phase to clear ground
• overworked with tight Achilles
• worse with up and down hill running

Question 18

Lateral shin splints:

Answer 18

• tensile stress on peroneus longus and brevis
• usually with supinated foot

Question 19

How to tell in shin splints are muscule vs bone

Answer 19

• RI: if it was musuclotendonious it would be painful
• bone: could use a tunning fork

Question 20

Shin splints and tenosynovitis additional factors

Answer 20

• ground reaction force: walking 1.2x BW, running 2x BW, jumpping 5x BW
• running surface considerations: soft surfaces (dirt/soft track), trail running (better but symmetrical)
• hard surfaces: asphalt, concrete increase GRF

Question 21

Crowned roads

Answer 21

• uphill sloped foot: pronates and angles into valgus
• downhil sloped foot = supinates and varus

Question 22

Additional common running injuries: ankle joint pain/ligamentous pain

Answer 22

• pronation and supination stress to ankle ligaments and joint s

Question 23

additional common running injuries: heel pain

Answer 23

- plantar fasciitis and or heel spur - heel pad breakdown as we age

Question 24

plantar fasciitis

Answer 24

- microtearing, inflammation of plantar fascia

Question 25

factors for plantar fasciitis

Answer 25

- over pronation/late pronation → tensile stress to plantar fascia - weak/fatigued extrinsic and intrinsic muscles, poor arches - G toe MTP extension ROM = inadequate windlass mechanism - a high arched foot with inherent tight plantar fascia - tight gastroc/soleus - pulls calcaneus posterior and puts tension on plantar fascia

Question 26

Windlass test

Answer 26

- extend G toe - = test for plantar fascia = heel pain

Question 27

Windlass test mechanism effect

Answer 27

- mid stance to terminal stance BW is transferred to metatarsal heads - normal extension of 1 MTP and other MTPs → tenses arch and plantar fascia resulting in calcaneal inversion → STJ, MTJ supination - w/o windlass mechanism arch and plantar fascia dont tense - and if there is weak extrinsics and intrinscis → lose stability and foot pronates

Question 28

Plantar fascia interventions

Answer 28

- orthotics in short term offter pain relief - ionto: short term 2-4 weeks - stretching calf, plantar fascia - short term 2-4 months pain relief - night splints: initial 1-3 months/symptoms persist >6 months to keep foot from going into pF and tighening up Plantar fascia - low dye taping = short term 7-10 days - manual therapy: jt mobs, STM and nerve mobilization provide short term pain relief and increase function

Question 29

Tarsal tunnel syndrome typically occurs in who

Answer 29

- over pronators with fatigue of extrinsic and intrinsic muscles and poor arch support

Question 30

What happens with tarsal tunnel and what are S&S

Answer 30

- inflammation of posterior tibial nerve, flexor retinaculum tightness and tenosynovitis PT, FDL, FHL S&S - parethesia plantar aspect of foot - may lead to weakness of intrinsics - claw toe - responds to orthotics and taping

Question 31

Metatarsalgia

Answer 31

- forefoot pain - between metatarsal - often hypermobility of foot = stresses on bone - musculature, ligaments, joint capsules

Question 32

Neuroma (Mortons)

Answer 32

- pain and paresthesia between 3rd and 4th toe - pinched nerves between metatarsals 3,4 - can be caused by tight shoes, hypomobility, compressed between ground and inter-metatarsal ligaments

Question 33

test for Mortons neuroma

Answer 33

- metatarsal squeeze test - compress the metatarsals together

Question 34

Treatment for motions neuroma

Answer 34

mobilization, shoes with proper toe box

Question 35

Factors related to stress fractures, in tibia and metatarsals

Answer 35

- supinated foot = increased GRF - hard surfaces; hard soles and heels - over training: microtraum and fatigue of fx bone, abnormal recovery, osteoblasts can't keep up with osteoclasts

Question 36

first stage of a stress fx

Answer 36

- gradual onset over 2-3 weeks - pain with activity such as running - pain relived with rest

Question 37

Progression stage of stress fractures

Answer 37

- pain for hours after running - night pain - fx of tibial cortex may become evidence - bone scan

Question 38

Clinical tests for stress fractures

Answer 38

- (+) pain upon palpation over fx site - (+) percussion test/pain with percussion at fx site - (+) tuning fork test - pain with vibration at fracture site - (+) pain w/ application of US at fx site

Question 39

Treatment for stress fx

Answer 39

- rest from running - allow bone healing - orthotic cushioned: dampen forces of supinated foot

Question 40

Exertional compartment syndrome

Answer 40

- increased intramuscular pressure in lower leg fascial compartment (no a lot of give) - influx of blood in working muscles - anterior, deep poster, superficial, lateral compartments

Question 41

Signs and symptoms of exertion compartment syndrome

Answer 41

- gradual onset of pain and tingling with exercise - ischemia to nerves and muscles within compartment - palpation: tenderness, tightness, diminished pulses (vascular can be compromised) - relieved with rest

Question 42

Treatment for exertion compartment syndrome

Answer 42

- soft tissue mobilization of compartment and stretching - activity modification - stop exercise at pain onset and rest - resume exercise to pain, stop, rest repeat - sometimes surgery is needed to cut fascia and release the pressure

Question 43

Acute compartment syndrome

Answer 43

- emergent - trauma: severe contusion, crush injury, fx - excessive bleeding and acute rapid increase in volume and pressure - anterior, lateral, posterior compartments - anterior is the most common and has thick fascia - causes compression of vascular, neural and muscle tissue

Question 44

Signs and symptoms of acute compartment syndrome

Answer 44

- acute intense pain, tingling, numbness not relieved by rest - diminished pulses, paresthesia, weakness, "drop foot" - medical emergency: irreversible tissue damage within hours - surgery: fasiotomy

Question 45

what to do with subtalar joint neutral test

Answer 45

- STJN talus is neutral in mortis - assess alignment of rearfoot on leg and forefoot on rearfoot - assess in NWB and WB

Question 46

Navicular drop test

Answer 46

- mark Navicular in STNJ allow relaxed stance and measure drop

Question 47

Rearfoot varus

Answer 47

- normal is 0-4 - greater than 4 is assoicated with a supinated foot

Question 48

Rear foot valgus

Answer 48

- assoicated with a pronated foot

Question 49

Rear foot varus in relation to lower leg

Answer 49

- inversion of calcaneus in STJ neutral - 0-4 varus is normal - assoicated with supinated foot

Question 50

Rear foot vaglus in relation to lower leg

Answer 50

- eversion of calcaneus in STJ neutral - associated with pronation

Question 51

forefoot valgus

Answer 51

- forefoot is everted in respect to rear foot when in STJ neutral - pronation stresses and instability of 1st ray to push off - 5th ray is up

Question 52

forefoot varus

Answer 52

- forefoot inverted (1st ray up) in respect to rear foot in sTJ neutral - in WB compensation brings 1st ray, forefoot to floor - result is late pronation, pronation stresses - instability 1st ray at push off - 1st ray is up

Question 53

Feiss line test

Answer 53

- in WB testsfor pronation - similar to navicular drop test - medial malleolus, navicular tubercle and metatarsal head are in a line

Question 54

Lacking Talocrual DF/gtoe extension compensation

Answer 54

- compensation Hip ER, push off medial foot - that can increase pronation but stress STJ and MTJ

Question 55

Rigid supinated foot | Compensations

Answer 55

- walk on lateral foot becomes painful - compensation increased pronation but that stresses hypo STJ, MTJ, intertarsals, TMT, causes pain

Question 56

Forefoot varus/inverted 1st ray

Answer 56

- WB compensation brings 1st ray , forefoot to floor - pronation stress to STJ, MTJ, intertarsal joints TMT

Question 57

Orthoics correct

Answer 57

- dont change the foot rather change the floor - alignment of rear foot to lower leg - alignment of forefot to rear foot - prevent abnormal stress

Question 58

Types of orthotics:

Answer 58

- t provide motion control and support rigid, semi-rigid orthoic = pronation correction - shock absorption orthoic spreads foreces and increases ground contact for a supinated foot

Question 59

Match footwaer to foot

Answer 59

- supinator = cushioned shoe for shock aborption - neutral foot: neutral stability shoe - over pronator: motion control shoe to control pronation adequate toe box

Question 60

Chi runner vs RS

Answer 60

- chi runners: forefoot/midfoot strikers; contact ground in PF (need eccentric control) - RS: rearfoot heel strikers (have greater vertical forces and need knee extensors to work to counter act the GFR causing knee flexion)