Foot and Ankle Theory Flashcards
List the traits of a tendinopathy (Achilles).
Non-inflammatory, rather a failed healing response.
i) degenerative changes in the tendon
ii) increased secreted ground substance proteins
iii) collagen deterioration
v) focal areas of fibroblast proliferation and vascularity
Describe how a tendon changes in the context of tendinopathy.
i) Collagen fibres become looser and in dissarray
ii) tendon becomes thicker
iii) Higher concentration of Type II collagen fibres and proteoglycans (which trap water and contribute to swelling)
Describe the typical presentation of an Achilles Tendinopathy.
i) pain especially in the mornings or after prolonged rest
ii) pain with activity
iii) Swelling and impaired function
Describe Hallmark features of treatment for Achilles tendinopathy.
i) eccentric tendon strengthening (more effective in younger athletic population, more effect slow and heavy than high reps). Reduced amount of DF for insertional tendinopathy. Use externally times cues.
ii) isometrics for analgesia
iii) Manual therapy for joint restrictio and soft tissue work.
iv) stretching into DF
v) heel lifts, orthotics, night splints
vi) low evidence for LLLT, shockwave, corticosteroid injections
vii) some evidence for PRP
viii) rigid taping
ix) iontophoresis with dexamethasone
Describe appropriate outcome measures for Achilles Tendinopathy
i) VISA-A
ii) LEFS
iii) Limb Symmetry Index
iv) hop test, heel raise endurance test
List important areas to palpate to rule out fracture.
i) medial malleolus
ii) lateral malleolus
iii) 5th MT process
iv) navicular
v) lateral process of talus (combine inv and DF)
vi) posterior process of talus (lat tubercle from compression via extreme PF or avulsion via PTFL on forced inversion) (med tubercle rare on only from avulsion of last 3rd of deltoid lig on DF and pronation)
vii) anterior process of the calcaneus (compression w/ forced DF or avulsion via bifurcate ligament w/ forced PF and inv)
Where would the sites of tenderness be for a talar osteochondral injury?
i) lateral dome anterior to lat malleolus
ii) medial dome posterior to med malleolus
Describe the MOI and best test for a suspected ankle syndesmotic injury.
Forced DF and ER
i) squeeze test
ii) TOP syndesmotic ligaments
What is a typical complaint in the case of cuboid subluxation following ankle inversion injury?
Pain in lateral foot on push off.
Describe the mechanism of ankle impingement following lateral ankle sprain.
i) laxity of ATFL allow for anterior translation of talus during DF
ii) thickening/scarring of capsular tissue
List the contents of the sinus tarsi.
i) fatty tissue ii_ part of extensor retinaculum iii) blood vessels iv) cervical and interosseous ligaments v) part of subtalar joint capsule vi) lateral subtalar px w/ WBing vii) nerve endings
List risk factors for 1st MTP OA.
i) osteochondritis dessicans
ii) trauma
iii) hypermobile first ray
iv) gait deviations
v) narrow footware
vi) long metatarsal
Desccribe the presentation of 1st MTP OA.
i) pain and swelling of 1st MTP
ii) plantarflexed forefoot and DF 1st ray relatively
iii) reduced MTP ext
iv) +ve grind test
vi) reduced toe flexion strength
vii) less push off toe ext in gait w/ pain in that phase
Desccribe treatment components for 1st MTP OA.
i) plantar and dorsal glides for mobility/stretching
ii) joint trxn for pain relief
iii) strengthen 1st toe ABD, ADD, ext and flex
iv) TrPR and STR of foot and calf
v) orthotics
vi) gait training
v) surgery (arthrodesis, arthroplasty, debridement, osteotomy)
Describe the presentation of Hallux valgus
i) valgus 1st phalanx
ii) attentuated weak medial collateral ligament
iii) weak lengthened ABD hallicis and short tonic ADD hallucis
iv) inefficient tib post/fib longus coupling causing prolonged pronation
vi) bunion formation
vii) lateral subluxation of FHB sesamoids and FHL tendon
Describe the treatment for hallux valgus
i) strengthen FHL and ABDH
ii) lengthen EHL and ADD halluciss
iii) toe spacers/add bracing overnight
iv) orthotics
v) gait training
vi) manual medial and plantar glides to normalize med capsular mobility
v) joint trxn and STR
vi) sesamoid mobilisation
vii) surgery
Describe the pathology of osteochondritis dessicans.
i) Idiopathic focal deterioration of subchondral bone leading to instability of the joint and displacement of djoint articular cartilage.. Precursor to arthritis. Primarily found in knee, ankle and elbow.
Describe the presentation of osteochondritis dessicans of the elbow.
i) overuse of the joint WBing (primarily gymnasts,) occurs and the capitulum
ii) pain laterally on valgus stress test while other injuries give medial pain on valgus stress
iii) lateral elbow pain, pain on posterolateral joint
iv) weakness, popping, clicking
vi) edema
Describe the presentation of osteochondritis dessicans of the knee.
i) May lock acutely
i) intermittent pain and edema - hemoarthrosis
ii) loose bodies
iii) responds to conservative Rx if fragment stable and pt juvenile
Describe the pathology of plantar fasciiopathy
Acute or chronic inflammatory process in the early stages. Upon symptomatic threshold, degeneration and filed repair more the case than inflammation.
Describe the objective findings of plantar fasciopathy.
i) reduced DF
ii) limited 1st MTP ext
iii) High BMI
iv) +ve Windlass test
v) TOP med calcaneal tubercle
Describe the treatment of plantar fasciopathy.
i) STR and TPR of gastrocs/soleus and PF
ii) joint mobilisations of the foot/ankle as indicated
iii) Strengthen toe flexors, inversion and eversion
iii) balance training static and dynamic
iv) high load strength (PF and toes extension strength at 8-12 RM)
v) forefoot extension exercise
vi) stretching
vii) taping (navicular lift and calcaneal reposition)
vii) orthorics
viii) night splints (research controversial)
ix) footwer (rockerbottom shoe)
x) shockwave
xi_ corticosteroid injection
Surgery if fails..
80-90% resovle w/in 6-12mo of conservative treatment
Describe the pathology of stress fractures.
When mechanical stresses causing osteoclast activity surpass the rate of bone remodeling or osteoblast activity resulting in a crack and propagation/poorly remodelled bone
i) increased stresses to normal bone causing microdamage to reach a certain threshold
ii) normal stresses over abnormal bone/bone metabolism (ie common in people w/ metabolic disorders or OP)
What are the risk factors for stress fracture in runners?
i) increased navicular drop
ii) increased PF ROM
iii) increased hip ER ROM
iv) high BMI
