High Yield 4 Flashcards
MOI tib plateau #
Axial loading force + varus/ valgus force causing articular shear, depression + malalignment
Pedestrian struck in lower leg, passenger in MVA, fall from height, violent twisting force
Conditions associated w/ tib plateau # + common mechanisms
Lateral plateau # + MCL (d/t valgus force)
Medial plateau # + LCL, PCL, medial meniscus (varus force w/ axial load)
Compartment syndrome
Sx + physical of tib plateau #
Painful, swollen knee
Inability to wt bear
Physical
Effusion
Decreased active + passive ROM
Tenderness proximal tibia
Ix for tib plateau #
XR - AP, lateral, tib plateau view (AP w/ knee in 10 degrees flexion), oblique
MRI or CT
In ?tib plateau #, what sx would make you consider compartment syndrome?
Pain not over fracture site
Pain on passive stretch
Paresthesia
Abnormality of pulses
Pressures >30 mm Hg—indication for fasciotomy
DDx for tib plateau #
Knee dislocation
Cruciate ligament tears/avulsion
Collateral ligament tears/avulsion
Meniscal tears
Quadriceps tendon rupture
Patellar fracture
Patellar dislocation
Management of tib plateau #
Long leg splint
Ice, elevation
Surgery or non operative management
Full extension brace x10 days then hinged knee brace
Non wt bearing x4-6 wks
Repeat XRs q2-3wks
Healing = 12-20 wks
When to refer for surgery in tib plateau #
Lateral plateau fracture with:
Articular step off >3 mm
Condylar widening >5 mm
Coronal plane instability
Displaced medial plateau fracture (60% of weight-bearing through medial plateau)
Bicondylar fractures
Fracture dislocations, vascular injuries, and compartment syndrome
Sx of patella/ quadriceps tendinopathy
Anterior knee pain worse w/ jumping or running or prolonged knee flexion
Progressive
RF for patella/ quadriceps tendinopathy
Running or jumping sports (volleyball, basketball, soccer, track + field)
Poor flexibility of quads + hamstrings
Use of fluoroquinolone abx within 90 days
Underlying CTD
Physical for patella + quadriceps tendinopathy
Patellar tendinitis: localized tenderness at the patellar tendon origin (inferior pole of the patella), patellar tendon midportion, and/or patellar tendon insertion (tibial tubercle)
Quadriceps tendinitis: localized tenderness at the quadriceps tendon midportion and/or quadriceps tendon insertion (superior pole of the patella)
Both: pain reproduced with extension of the knee versus resistance and/or with maximal stretching of the quadriceps
Both: poor flexibility of the quadriceps and hamstrings
DDx for patella/ quadriceps tendinopathy
Patellofemoral pain syndrome
Hoffa disease (fat pad impingement)
Osgood-Schlatter disease
Sinding-Larsen-Johansson syndrome
Chondromalacia patella/patellofemoral osteoarthritis
Osteochondral lesions
Patellar subluxation/dislocation
Patellar stress fracture
Patellar tendon rupture (partial or complete)
Quadriceps tendon rupture (partial or complete)
Lumbar radiculitis/radiculopathy involving the L3 and/or L4 nerve roots
Management of patella/ quadriceps tendinopathy
Relative rest, ice, NSAIDs, topical nitro patch
Patella tendon strap
Stretching + strengthening”
quadriceps, mainly single leg squats with a slow negative phase
Percutaneous intervention if failed conservative rx x6mo
Needle tenotomy
Platelet-rich plasma (PRP)
Prolotherapy
Tendon scraping or hydrodissection, separating the peritenon/fat pad from the tendon, disrupting the neovessels and nerves
Shock wave therapy
MOI patella / Quadriceps tendon rupture
Rapid, eccentric contraction w/ knee in partial flexion + foot planted
Landing from a jump, falls.
Patella tendon ruptures are usually complete
RF patella / Quadriceps tendon rupture
More common in males
Patellar tendon rupture typically < 40 years
Quad tendon typically > 40 years
Quad tendon rupture is more common than patellar tendon rupture
Corticosteroid in tendon
SLE, RA
DM
Obesity
Hx of tendinosis
Fluoroquinolones
High jump, basketball, wt lifting
Previous TKR, ACL reconstruction using patella graft
Sx of patella / Quadriceps tendon rupture
Pop
Immediate disabling pain
Unable to wt bear or straighten knee
Acute onset swelling
Physical for patella / Quadriceps tendon rupture
Audible crepitus
Often unable to weight bear
Often large hemarthrosis and bruising
Unable to do a straight leg raise or maintain a passively extended knee
Patella alta (patella is superiorly displaced) in complete patellar tendon rupture
Patella baja (patella is inferiorly displaced) in complete quadriceps tendon rupture
Palpable defect (may be masked by swelling acutely or by scar tissue in delayed evaluation)
Tenderness to palpation over patellar poles, retinaculum, or tibial tuberosity
Absence of/altered patellar tendon reflex
Altered gait if able to bear weight
Quadriceps atrophy (in chronic cases)
Ix for patella / Quadriceps tendon rupture
US usually used
MRI is gold standard
DDx for patella / Quadriceps tendon rupture
Fracture
Muscular strain (grade I or II)
Patellar subluxation/dislocation
Meniscal or ligamentous pathologies
Osgood-Schlatter disease
Sinding-Larsen-Johansson syndrome (inferior patella pain d/t repeated stress on growth plate)
Management of patella / Quadriceps tendon rupture
Immobilize w/ straight leg splint, ice, elevation
Refer to ortho
Incomplete - can be treated non operatively
Immobilization and protected ambulation for 6 wk, followed by a hinged brace allowing active extension in situ until pain resolves
Surgery is indicated for:
complete ruptures
incomplete ruptures failing to respond to nonoperative treatment
Ideally within 2 wks
Rehab for patella / Quadriceps tendon rupture
Immobilise x6 wks - during this time, work on active flexion + passive extension exercises
6 wk onward: straight-leg raise exercises
8 wk onward: stationary biking and water running
3 mo onward: progressive quadriceps exercises
4 mo onward: jogging
9 mo onward: jumping and contact sports permitted
Comprehensive physical therapy program should be completed before return to athletics
Complications of patella / Quadriceps tendon rupture
Loss of flexion is common after quadriceps tendon rupture.
Extensor mechanism weakness
Postoperative infection
Degenerative change at the patellofemoral joint
What is a Bakers cyst, and what are the types?
Cystic enlargement of the gastrocnemius-semimembranosus bursa, located on the medial side of the popliteal fossa between the medial head of the gastrocnemius and the semimembranosus tendon:
Primary cysts arise with no communication into the joint (more common in children).
Secondary cysts are associated with communication between the bursa and joint capsule (more common in the adult population)
RF for bakers cyst
Trauma
Intra-articular knee pathology (meniscal tears, OA, RA, ACL tear)
Sx of bakers cyst
Usually asymptomatic
Posterior knee pain, swelling, palpable mass, knee stiffness
Can have leg swelling, calf pain
Physical of bakers cyst
Palpable medial popliteal mass
Examine in full extension + 90 degrees flexion
Foucher sign
Tense cyst with knee in extension softens or decreases in size with knee flexion
Change in findings related to knee position helps to differentiate popliteal cyst from solid masses
Homans sign
Discomfort in the calf muscles on forced dorsiflexion of the foot with the knee straight
Indicates DVT but can be positive in Baker’s cyst
Ix for bakers cyst
US or MRI
Management of bakers cyst
Manage underlying joint pathology
May not need treatment of cyst if asymptomatic
If symptomatic w/o vascular or neurogenic compression:
Rehab to maintain knee flexibility
Direct cyst aspiration + steroid inj
If conservative x6 wks does not work or if vascular or neurogenic compression, refer for surgery
Complications of bakers cyst
Cyst rupture or dissection
Enlarged cyst may compress adjacent vein, resulting in pseudothrombophlebitis or thrombophlebitis with symptoms of leg swelling and erythema.
Compression of tibial nerve may result in neuropathy, plantar foot numbness, or gastrocnemius atrophy.
Compression of popliteal artery may lead to limb claudication or ischemia.
Compartment syndrome may result from cyst rupture, which requires emergent management.
DDx of bakers cysts
Deep vein thrombosis (DVT)
Popliteal artery aneurysm
Solid tumors (lipoma, sarcoma, etc.)
Other cystic structures (ganglion cyst, meniscal cyst, myxoid tumors)
RF + MOI for PCL tear
Contact sports (football, soccer, skiing, wrestling)
MOI
Dashboard injury in MVA (Posteriorly directed force to anterior proximal tibia in flexed knee)
Sx of acute vs chronic PCL tear
Acute:
Pain in posterior knee
Pain w/ kneeling
Feeling of instability
Rapid onset swelling
Chronic:
Vague anterior knee pain
Pain with or inability to descend inclines/stairs, deceleration, or running at full stride
Physical for PCL tear
Perform neurovascular exam before other provocative tests
If combined with an ACL injury, assume vascular injury, perform ankle-brachial index, and, if low stat, referral to vascular surgeon
Posterior drawer test positive
Posterior sag positive
Quadriceps active test positive
Perform with the patient supine and knee flexed at 90 degrees and hip flexed at 45 degrees.
Examiner stabilizes the foot, and the patient attempts to extend the knee while the examiner applies a counter force against the ankle.
Patient also may be asked to activate quadriceps by sliding foot down the table.
In a PCL-deficient knee, the posteriorly subluxed tibia will translate anteriorly with quadriceps activated.
Dynamic posterior shift test:
Patient is supine with knee and hip flexed at 90 degrees.
Examiner slowly extends knee.
With a PCL tear, there will be “clunk” near full extension when the posteriorly subluxed tibia is reduced.
Ix for PCL tear
XR: AP, lateral, sunrise, tunnel, oblique + stress views
Stress XRs (lateral XR with knee flexed + posteriorly directed force applied to proximal tibia): 8mm or more posterior tibial translation is indicative of complete PCL tear
MRI gold standard
DDx for PCL tear
ACL tear
Tibial or fibular fracture
Medial or lateral collateral ligament tear
Meniscal derangement
Posterolateral corner injury
Knee and/or patella dislocation
Management of PCL tear
Acute
Ice, compression, elevation, immobilization (partial wt bearing, full extension for grade 3 lesions)
Refer to ortho
Non operative indications:
Isolated grade 1 + 2 tears
RTP 2-4wks w/ knee brace
PT
Multiphase with time-specific and objective finding–related phases
Progressive weight-bearing
Quadriceps strengthening
Immobilization initially, with progressive addition of flexion until full range of motion (ROM) achieved
Functional PCL brace may be useful but not proven effective
Indications for surgery in PCL tear
Associated bony avulsion fractures.
Multiple ligament injuries.
Persistent pain in grade 3 lesions.
Chronic symptomatic instability with activities of daily living or with sports.
Acute grade 3 injury in young, active patient
Complications of surgical vs non surgical care of PCL tear
Nonoperative:
Chronic PCL laxity
Progressive medial compartment and patellofemoral degenerative changes
Increased risk of meniscal tears, articular cartilage injury with chronic PCL insufficiency
Operative:
Most common: residual laxity
Iatrogenic neurovascular injury (especially of the popliteal artery)
Loss of motion
Infection
Medial femoral condyle osteonecrosis
Anterior knee pain
Painful hardware
RF for Patellar subluxation + dislocation
Prior history of subluxed or dislocated patella
Recurrence rate 15–50% after initial dislocation
Adolescent females
Patella alta (“high-riding patella”)
Excessive genu valgum
Weak vastus medialis
Excessive tibial torsion
Family history of patellar instability
Trochlear dysplasia
Lateralized tibial tuberosity
Weak hip abductor and external rotator muscles
Risk factors associated with developmental dysplasia (firstborn girl, high birth weight, deliver by cesarean section, breech delivery)
Sx of Patellar subluxation + dislocation
Severe pain, pop
Consider subluxation if hx consistent w/ dislocation but pain resolved
Physical for Patellar subluxation + dislocation
Immediately after dislocation, may show patella dislocated laterally and prominence medially due to uncovered medial femoral condyle
Obvious effusion
Tenderness most apparent over the medial edge of patella and lateral femoral condyle
Limited range of motion with knee in extended position
Fear of redislocation when knee is flexed
Positive apprehension sign with movement of patella laterally
Check anterior cruciate ligament (ACL) and meniscus, as up to 12% of patellar dislocations have associated major ligamentous or meniscal injury.
“J” sign: Seated patient straightens the knee; the patella moves outward instead of straight upward.
Ix for Patellar subluxation + dislocation
XR
MRI
Management of Patellar subluxation + dislocation (acute)
Reduce (may need conscious sedation): leg in extension w/ hip flexed (reduces tension of quad tendon), apply Gentle pressure on patella directed lateral to medial
Postreduction XRs
RICE
Knee immobilization x2-3 wk
Wt bearing as tolerated after 1 wk
Aspiration if hemarthrosis present to reduce pain - check for fat globules (would help dx osteochondral #)
When to refer to ortho for Patellar subluxation + dislocation
Osteochondral fracture
Recurrent patellar dislocations despite adequate rehabilitation, especially in younger patients (<14 yr old), in whom recurrence rates can reach 60%
Evidence of joint locking
High-risk athlete participates in activities involving pivoting and is at increased risk of recurrent patellar dislocation
PT, type of brace + RTP for Patellar subluxation + dislocation
PT
Isometric quadriceps exercises immediately
Active range of motion exercises at 1 wk
quadriceps and lateral hip strengthening
Bracing
Hinged brace is used for ambulation until 100 degrees of painless flexion is present, there is no effusion, and a normal heel-to-toe gait is possible.
Then neoprene sleeve until normal, painless activities of daily living are possible.
RTP
There should be evidence of adequate healing (absence of sensations of instability, lack of effusion, and absence of pain on patellofemoral compression) and adequate function (able to perform rotational movements such as pivoting, cutting, and twisting without evidence of instability) for return to sports
Athlete may need McConnell taping or patellar stabilizing braces to accomplish this.
What is a knee dislocation?
Complete disruption of tibiofemoral articulation
Types of knee dislocation with associated MOI + other injuries
Dislocation is described as the displacement of the tibia relative to the femur
Anterior dislocation (40%):
Hyperextension of the knee of at least 30 degrees
Rupture of the posterior capsule followed by the PCL
Posterior dislocation (33%):
Direct blow to the anterior tibia with the knee flexed at 90 degrees (“dashboard” injury or falling onto flexed knee)
ACL is usually spared.
Medial dislocation (4%):
Varus stress causing tear to ACL, PCL, and LCL; highest risk of posterolateral corner (PLC) damage and thus the highest risk of irreducible dislocation
Associated with tibial plateau fracture
Lateral dislocation (18%):
Valgus stress causing tear to ACL, PCL, and MCL
Associated with tibial plateau fracture
Complications of knee dislocation
Popliteal artery injury (64% of dislocations) - only 6 hr window to prevent permanent ischemic damage
Fibular nerve injury (50% of dislocations)
Characterized by hypesthesia of anterolateral leg and dorsum of foot, weakness of ankle dorsiflexion
RF for knee dislocation
More common in young males
Morbid obesity
Contact or high velocity sports
Sx of knee dislocation
Pop
Knee pain and instability
Often unable to weight bear
Physical for knee dislocation
Difficulty weightbearing
If knee dislocation has not spontaneously reduced, deformity is obvious (and should present to the ED). Most (especially the lower energy sporting injuries) reduce spontaneously
Dimple sign: dimple of the medial skin and soft tissues
Pucker sign: Puckering of skin results from its attachment to the invaginated capsule
A key sign is extensive bruising of either medial or lateral knee, which is from a hemarthrosis that has leaked out from a torn joint capsule
If high impact injury + multiple ligaments unstable, suspected relocated knee dislocation
Vascular exam:
By palpation, Doppler, ankle-brachial pressure indexes, and distal perfusion
Dorsalis pedia, posterior tibialis, popliteal
Popliteal thrill or expanding pulsatile hematoma
Signs of distal ischemia: pallor, paresthesias, pain, paralysis, unequal temperature
If peripheral pulses are normal initially, it is essential to do serial, frequent exams with documentation of pulses
Neuro exam:
Sensory: anterolateral lag, dorsum of foot, first web space
Motor: ankle dorsiflexion, eversion
DDx for knee dislocation
Tibial plateau fracture
Supracondylar femoral fracture
Isolated fibular nerve injury
ACL injury/rupture
Ix for knee dislocation
CBC, Cr, INR
XR to r/o # but may be normal
ABI
Systolic BP x4 limbs w/ Doppler probe
Highest pressure from dorsal pedal pulse or posterior tibial pulse / highest brachial BP
If asymmetric pulses or ABI <0.9, perform angiography
MRI
Treatment for knee dislocation
Support ABCs
Splint in 20 degrees flexion to prevent traction or compression of the PA
Get to hospital ASAP + contact ortho immediately - plan to reduce in ED
In ED:
Reduce to reduce pressure on neurovascular structures
If pucker or dimple sign present, suspect posterolateral dislocation which is irreducible - consider immediate open reduction in ED
Refer to ortho +/- vascular
Admit for serial ABI + pulse exams x48 hrs
Rehab:
Goal of 90 degrees knee flexion 6 wk postoperatively and 120 degrees at 12 wk
No return to full activity or sports before 9 mo
Complications of knee dislocation
Amputation
Compartment syndrome
Neurovascular deficit
Chronic pain
Stiffness
Instability
RF for PFPS
Recent increase in training
Increased running, squats, lunges
Patella hyper or hypomobility
Malalignment
Valgus/ varus deformity
Common in young teens
Specialisation of single sport leads to higher incidence
Sx of PFPS
Diffuse anterior knee pain
Associated w/ squatting, running, stairs, prolonged sitting
Persists for years
Pain on knee straightening
Physical for PFPS
Crepitus/ grinding
Anterior knee pain during squatting
Tenderness on patella edges
DDx for PFPS
Patellar or quadriceps tendinopathy
Patellofemoral osteoarthritis
Patellar instability with subluxation or dislocation
Osteochondral defect of the trochlear or patellar surface
Osteochondritis dissecans
Iliotibial band syndrome
Infrapatellar fat pad inflammation or impingement
Synovial plica
Retinacular strain
Osgood-Schlatter apophysitis (proximal anterior tibia)
Sinding-Larsen-Johansson apophysitis (inferior patellar pole)
Referred pain from the hip, often affecting the anterior distal thigh and knee
Management of PFPS
Rx
Foot orthotics/ supportive shoes
Ice, compression, elevation for acute pain control
Taping (McConnell)
PT
Activity modification recommendations + home exercises
Reduce aggravating activity (running, squatting)
Encourage other activities (swimming, cycling)
Combined hip + knee exercises preferred
Isometric quadriceps strengthening (push knee into floor with leg straight)
Straight leg lift from floor slowly
IT band stretches
Hamstring stretches
Hip adductor strengthening by squeezing ball between legs
Calf stretch
RTP
If patient has PFP during, immediately following, or the day after exercising:
Decrease activity. Avoid strength training exercises such as full squats and lunges.
Consider alternate activities, such as an elliptical trainer, bicycling, or swimming.
Runners who need to maintain running-specific conditioning, use a floatation belt for pool running.
Sx usually resolve within 4 wks
MOI meniscal injury
Twisting, shearing or compressive force
Usually twisting through a flexed, planted knee
RF for meniscal injury
Male gender
Abnormal mechanical axis
Playing soccer or rugby
Ligament deficiency
Degenerative joint disease
Discoid meniscus
Poor quadriceps control
Waiting >12 mo between ACL tear and reconstruction surgery is a risk factor for medial meniscus tear
Conditions commonly associated w/ meniscal injury
ACL
Tib plateau #
Sx of meniscal injury
Pain with walking, stairs, squatting, kneeling, prolonged sitting
Onset after plant + pivot action
Slow onset swelling
Catching, locking, clicking
Giving way
Exam of meniscal injury
Locked knee (bucket handle tear, ligament tear or loose body)
Effusion + joint line tenderness
McMurray positive
Thessaly positive
Ix for meniscal injury
XR wt bearing (AP, lat, skyline, tunnel)
MRI
DDx for meniscal injury
Synovitis
Intra-articular loose body
Articular cartilage defect (OCD)
Ligamentous injury, particularly ACL and/or MCL
Patellar subluxation/dislocation
Degenerative joint disease
PFPS
Tibial plateau fracture
Management of meniscal injury
Initial: RICE
Surgery or
Non op (For small central tears or degenerative tears) - steroid shot, PT
Then:
Lower weight bearing activities (bike, swim)
Avoid plant/ pivot/ twist activities
PT addressing balance, quadriceps, and hamstring strength
RTP 6-12wks
When to refer for surgery in meniscal injury
Locked knee
Younger patients with vertical longitudinal tears in periphery of meniscus
Locking symptoms, flap tears, and bucket-handle tears.
Associated cruciate ligament injury, osteochondral defect, loose bodies, or fracture.
Nonurgent referrals include tears treated nonoperatively but that continue to cause pain or disability
Complications of meniscal surgical repair
Injury to peroneal nerve possible with lateral meniscus repair
Injury to infrapatellar branch of saphenous nerve possible with medial meniscus repair
Repair could fail, resulting in repeat arthroscopy.
Infection
Types of knee “locking”
“True locking” - mechanical block, usually extension blocked, caused by meniscus tear or loose body - sometimes a wiggle can unlock it
“Pseudo locking” - pain/ muscle contracture “locks” - can be in flexion or extension, d/t swelling, inflammation, patella maltracking, plica syndrome
Acutely locked knee is an orthopedic emergency
What is Osgood Schlatter’s?
Apophysitis (inflammation of growth plate (apophysis)) of tibial tuberosity at attachment to patellar tendon
Overuse injury
RF for Osgood Schlatter’s
Ages of growth spurts (girls 8-13 y/o, boys 12-15 y/o)
Males
Running + jumping sports
Excessive kneeling
Overweight
Sx of Osgood Schlatter’s
Anterior knee pain
Often bilateral
Worse w/ activity (running, jumping, kneeling), improves w/ rest
Chronic, insidious, fluctuant swelling
Physical for Osgood Schlatter’s
Tender tibial tuberosity
Prominent tibial tubercle
Able to maintain full symmetric knee extension w/ SLR
If inable to do this, highly suggestive of tibial tubercle avulsion #
Pain w/ resisted knee extension, active or passive knee flexion
DDx for Osgood Schlatter’s
Patellar tendonitis
Sinding-Larsen-Johansson syndrome
Tibial tubercle avulsion fracture
Tibial plateau fracture
Patellar fracture
Osteochondritis dissecans
Patellofemoral syndrome
Pes anserine bursitis
Patellar tendon rupture
Patellar subluxation
Chondromalacia patellae
Hoffa disease (infrapatellar fat pad impingement)
Osteomyelitis
Tumor
Management + recovery time of Osgood Schlatter’s
Relative rest
Activity as tolerated if sx resolve within 24hrs
NSAIDs
Ice after exercise
Lasts 6-18mo, self limiting (will resolve when growth plate closes)
Stretch quads + hamstrings + strengthen quads
If conservative treatment failed, consider surgical excision of enlarged tibial tubercle
Sx of medial tibial stress syndrome
Chronic, insidious, progressive
Medial distal ⅔ of tibia
Pain w/ activity, can improve as activity continues, can be painful at rest too
RF for medial tibial stress syndrome
Female sex
Higher body weight
Navicular drop (an indicator of excessive pronation)
Prior running injury
Limited external/internal rotation of hip
Limited ankle range of motion (ROM)
Higher body mass index (BMI)
Overall poor conditioning
Limited core strength
Physical for medial tibial stress syndrome
Tenderness to palpation along the middle to distal 2/3 of the tibia, along the posteromedial border
Diffuse posteromedial pain with palpation is most sensitive finding
Shoe exam shoes overpronation wear pattern, excessive wear of shoes
r/o stress # by hopping on one foot, vibration
Ix for medial tibial stress syndrome
XR + possibly bone scan to r/o stress fracture
DDx for medial tibial stress syndrome
Stress fracture
Compartment syndrome
Muscular strain
Nerve entrapment
Fascial defects
Popliteal artery entrapment syndrome
Management of medial tibial stress syndrome
Rx
Correct biomechanics, well cushioned shoe
Ice, NSAIDs
Complete rest ideally then cross training with pain-free activities
Stretching and strengthening
Physiotherapy - shockwave therapy
Taping
Activity modification recommendations + home exercises
Target-specific stretching and strengthening exercises
Core strengthening
Towel calf stretches
Tracing alphabet with toes
Alternate heel/toe walking
Prevention of medial tibial stress syndrome in future
Shock-absorbing insoles: most promising in studies
Pronation control insoles if navicular drop
Replacing running shoes after 300 miles/ 6mo wear
Gradually increasing running programs
Increase rest days
Cross training w/ non wt bearing activity
Sx of DOMs + physical findings
Hx
Delayed onset muscle soreness - muscle pain after training sensation. Typically starts 12 hrs after exercise, peaks at 24-48 hrs, stops after 5 days
Physical
Painful muscles, swelling, increased muscle girth, reduced passive stretch, reduced muscle strength
Prevention of DOMs
regularly participating in exercise that causes symptoms, warming up correctly, stretching + massage
Sx of heat cramp
Often a prodrome “cramp prone state” when muscle feels tight or painful. Cramps usually involve muscles which cross 2 joints (like calf, hamstrings or quads)
Painful, involuntary contractions of muscles
Commonly calf, quads + abdomen
Tense, tender, involuntary contraction of muscle belly
DDx for heat cramp
Gastroc/ soleus strain or tear
DVT
Popliteal artery entrapment
Referred pain from lumbar spine
Management of heat cramp
Rest
Oral rehydration + electrolyte replacement - IV if unable to tolerate by mouth
Passive stretching
Massage
Ice
Prevention of heat cramp
Training should be similar to match/ game intensity + duration
Passive stretching during play
Acclimatise to heat
Appropriate clothing
Hydration
What is the physiology that occurs in athletes when they acclimatise to hotter climates?
Increased blood volume and venous tone, earlier onset of sweating, more sweat volume, more diluted sweat
What is ITB friction syndrome?
Overuse tendinopathy that occurs from compression of the iliotibial band (ITB) against the lateral femoral epicondyle
Sx of ITB friction syndrome
Pain is especially sharp after foot strike in the gait cycle, usually at ~30 degrees of knee flexion
Lateral knee pain - sharp or burning
Pain is not present when the patient starts exercising but begins at a predictable time or distance within the workout.
Symptoms that subside shortly after the workout but return with the next workout
Pain worse with downhill running, stride lengthening, or sitting for long periods of time with a flexed knee
Involvement in sports that require continuous running or repetitive knee flexion (i.e., bicycling)
RF for ITB friction syndrome
Training factors: higher weekly mileage, downhill running, disproportionate running on a track in the same direction
Increased peak hip adduction (possibly owing to significant weakness of the hip abductors of one limb as compared with the other) and increased knee internal rotation during stance phase, with running
Physical for ITB friction syndrome
May notice local tenderness and swelling as well as crepitation, snapping, or pitting edema over the distal ITB where it passes over the lateral femoral epicondyle, and there may be pain or paresthesia along the length of the band
Positive Ober test
Position the patient on the unaffected side with the involved knee in 90 degrees of flexion. The leg is abducted at the hip, and the examiner then grasps the ankle and extends leg, allowing the knee to return to an adducted position. A person with ITB tightness will remain abducted
Positive Noble compression test:
With the patient on his or her side with the affected knee up and flexed at 90 degrees, apply pressure on the ITB at the lateral femoral epicondyle and extend the knee. A positive test occurs when pain occurs as the knee approaches 30 degrees of flexion
Leg length discrepancy can cause tightening of ITB
DDx for ITB friction syndrome
Patellofemoral syndrome
Degenerative joint disease
Lateral meniscal damage or pathology
Lateral collateral ligament sprain
Superior tibiofibular joint sprain
Popliteal or biceps femoris tendinopathy
Peroneal nerve injury
Gout and other metabolic arthropathy
Referred pain
Management + RTP for ITB friction syndrome
Rest, avoid aggravating activities
Ice, NSAIDs
PT - hip + core strengthening + stretching, foam roller
Gait training - increasing gait width, reducing hip adduction changing from heel strike to forefoot landing, and avoiding excess pronation
Can consider steroids but this increases risk of ITB rupture
Surgery for ITB release if no improvement w/ conservative therapy
RTP when sx have 100% improved - going back too early will cause significant delay
Usually 6 wks
Sx of chronic compartment syndrome
Usually lateral, diffuse leg pain
Often bilateral
Fullness, cramp-like, tightness type pain
Aggravated w/ impact activities
No pain at rest but pain w/ activity, usually specific amount of exertion every time
Resolves <30 mins after stopping activity
Associated w/ paresthesias + foot drop
Change in activity/ training intensity may have provoked sx
RF for chronic compartment syndrome
Rapid increase in repetitive activity
Participation in high-risk sport activities
Significant musculature of the lower extremity
Diabetes mellitus
Physical for chronic compartment syndrome
Normal exam at rest
Examine postexertion
Pain may become present
Muscle/facial tightness may be palpable
Neurovascular abnormalities may become present
Passive stretching of the muscles in the affected compartment may also cause pain.
Ix for chronic compartment syndrome
Needle manometry is gold standard
Pre + post exercise compartment pressures
DDx for chronic compartment syndrome
Acute compartment syndrome
Stress fracture
Medial tibial stress syndrome
Fascial hernia
Tendonitis
Popliteal artery entrapment syndrome
Peripheral nerve entrapment
Peripheral vascular disease
Referred pain (L4)
Exertional DVT
Management + RTP for chronic compartment syndrome
Conservative measures: stretch, soft tissue therapy (friction massage), correct biomechanics (rarely successful), forefoot training
Definitive management: fasciotomy, 80-90% success rate
Recurrence rate 20-30%
RTP 8-12 wks
Criteria for diagnosis of compartment syndrome based on compartment pressures
(1) preexercise/rest pressure of greater than 15 mmHg
(2) 1-minute postexercise pressure of greater than 30 mmHg
(3) 5-minute postexercise pressure of greater than 20 mmHg.
(4) Post-Exercise elevated pressure despite 15 minutes rest
MOI, physical findings + management of acute compartment syndrome
Usually associated w/ # or crush injury
Physical
Pain out of proportion to physical exam
Pain w/ passive stretching
Neurovascular abnormalities at rest
Management
Immediate consult for ortho surg
Emergency fasciotomy
Complications
Muscle necrosis
Sx of DVT
Can be asymptomatic
Swelling, pain, discoloration
PE sx can be first sign (SOB, CP, cough, hemoptysis)
Physical for DVT
Well criteria for DVT
Swelling >1cm compared to opposite leg
Palpable cord
Warmth
Superficial venous dilation
Homans sign - passive dorsiflexion of ankle elicits pain in calf
Ix for DVT
D dimer if low risk, if high risk + neg D dimer then do further imaging
Bilateral duplex US
CBC, PT as a baseline
?PE
do CT angiography or V/Q scan
ECG - S wave in lead I, Q wave in lead III, inverted T wave in lead III (S1Q3T3)
DDx for DVT
Superficial thrombophlebitis
Cellulitis
Torn muscles and ligaments
Ruptured Baker cyst
Bilateral edema (seen with heart, kidney, or liver disease) is rarely caused by DVT.
Prior DVT and postphlebitic syndrome
Arterial insufficiency
Arthritis
Lymphangitis
Extrinsic compression of iliac vein secondary to tumor, hematoma, or abscess
Hematoma
Lymphedema
Neurogenic pain
Prolonged immobilization or limb paralysis
Stress fractures or other bony lesions
Varicose veins
Management of DVT
If provoked, anticoagulation x3mo
If unprovoked 1st time, indefinite anticoagulation if low risk bleeding, if high risk bleeding then 3mo
Rivaroxaban 15mg PO BID x3 wks then 20mg PO daily
Apixaban 10mg PO BID x7 days then 5mg PO BID daily
Refrain from training x1mo
Compression stockings x9mo
Rehab + RTP for DVT
Light ambulation after 24hrs of anticoagulation
Weeks 1 to 3: reintroduction to activities of daily living
Week 4: begins engaging in non–weight-bearing activities (e.g., swimming)
Week 5: progresses to nonimpact-loading exercises (e.g., cycling)
Week 6: begins impact-loading exercises (e.g., running)
Week 6+: A gradual transition to sport-specific protocols as well as an increase in the duration and intensity of training may be initiated
No contact sports while on anticoagulation
Prevention of DVT
Avoid prolonged immobility.
Hydrate adequately.
Consider compression stockings when immobilized.
Caution when using birth control; use low-estrogen pills when possible.
Prophylaxis for hospitalized patients
When travelling:
Hourly walking breaks
Loose clothing
Avoid crossing legs
RF for DVT
Immobilisation (trauma, long flights, post op)
Pregnancy
Malignancy
Smoking
Steroids
Dehydration
Increased age
Antiphospholipid syndrome
Estrogen therapy
Fam hx
Obesity
Trauma
Clotting disorder (factor V leiden, antithrombin deficiency, protein C or S deficiency)
MOI hamstring strain
Excessive load during an eccentric contraction, such as with running or jumping
Usual mechanism of injury occurs in the later part of the swing phase as the hamstrings rapidly change from eccentrically working to decelerate knee extension to concentrically becoming an extensor of the hip
RF for hamstring strain
Strength imbalances, flexibility, core strength, lumbopelvic position, and fatigue
Prev hx of hamstring injury
Sx of hamstring strain
Usually acute: sudden onset posterior thigh pain
Chronic presents w/ tightness
Physical for hamstring strain
A “stiff-legged” gait may occur as patient tries to avoid hip flexion with knee extension.
Position patient prone and inspect for swelling and/or ecchymosis.
Palpate the entire length of each hamstring muscle going from common origin on ischial tuberosity moving distally until insertion on fibular head (BF), medial femur (SM), and medial tibia (ST)
DDx for hamstring strain
Direct hamstring injury, including muscle laceration or contusion (common direct mechanism for injury as opposed to indirect strain mechanism)
Posterior lateral corner knee injury, meniscal injury, or popliteal cyst formation or rupture
Pelvic or proximal femoral stress fracture
Piriformis syndrome, gluteus medius injury, or adductor strain
Pain radiating from the lumbar back, sacroiliac joint, or hip
Management + RTP of hamstring strain
Acute
Goals: control pain, swelling, hemorrhage, and muscle fiber adhesion; work toward restoration of normal gait
Protection, rest, ice, compression, and elevation (PRICE)
Subacute/ rehab
Advance activity as tolerated
Core strength
Lumbar stability
Nordic hamstring exercises
RTP
When pain free - can be weeks to months
Surgery
Consider in severe proximal or distal injuries
Prevention of hamstring strain
Nordic hamstring exercises
What makes up the hamstring?
Biceps femoris
Semitendinosus
Semimembranosus
RF sports + MOI for proximal hamstring tendon rupture
RF
Sprinters, water skiers
Mechanism
Forceful knee extension while hip joint is in flexion
Sx + physical for proximal hamstring tendon rupture
Pain and bruising in posterior thigh
Stiff leg gait (they don’t want to stretch hamstring by flexing hip, or activate it by flexing knee)
Bruising
Often can palpate retracted muscle
Weakness and pain with resisted knee flexion
Ix for proximal hamstring tendon rupture
X-rays to look for avulsed bony fragment, US or MRI to confirm
Management of proximal hamstring tendon rupture
Operative repair suggested for complete proximal avulsions, or 2 tendon involvement in young, active individuals if there is retraction. Suggest: obtain imaging and refer above semi-urgently.
What is a Lisfranc injury?
Spectrum of injuries from sprain to dislocation
Lisfranc complex is 1st, 2nd + 3rd metatarsal base, cunieforms + cuboid bone + ligaments
Lisfranc ligament is between medial cunieform + 2nd MT
MOI Lisfranc injury
Direct trauma (heavy object dropped on dorsum of midfoot or crush injury)
Indirect: (twisting force on a plantar-flexed foot)
eg football or soccer player is tackled while their foot is caught or planted)
Step-off injuries: Missing a step or misjudging a landing, causing the forefoot to rotate while the midfoot remains fixed
RF + commonly associated conditions w/ Lisfranc injury
RF
Males
Commonly associated conditions
Cuneiform and cuboid fracture dislocations
Compartment syndrome of the foot
Sx + physical for Lisfranc injury
Midfoot or diffuse pain
Swelling
Physical
Pain w/ wt bearing, pain on tip toes
Midfoot swelling
Plantar ecchymosis is classic
Tenderness over tarsal-metatarsal joint
Passive pronation and supination of forefoot can cause pain
Pain w/ stress of midfoot
Chronic - instability causes flattening of arch
Ix for Lisfranc injury
XRs (AP, internal oblique, lateral) - wt bearing increases sensitivity
widened interval between 1st + 2nd MTS
increased displacement between the medial cuneiform and 2nd MT base
Increased interval between the medial and intermediate cuneiforms
CT good for subtle injuries
MRI good for ligament
DDx for Lisfranc injury
Lisfranc fracture dislocation
Tarsometatarsal sprain
Metatarsal fracture
Cuboid fracture
Cuneiform fracture
Management + RTP of Lisfranc injury
Grade 1
Immobilization in short walker boot with protected weight-bearing x2 wks
Then short boot w/ wt bearing as tolerated x4 wks
Walking without boots at 6 wks
No high-impact activity for first 3 to 4 mo after injury
Single leg hop test pain free before activity
Injuries beyond grade 1, particularly any injuries with displacement on x-ray or evidence of dynamic instability
Refer to surgeon, non wt bearing
ORIF
Complications of Lisfranc injury
Compartment syndrome
Post traumatic arthritis
Progressive foot deformity + functional impairment
Sx of achilles tendinopathy
Pain in posterior calf + heel
Initially subsides w/ use but returns w/ continued use
Morning stiffness
Weakness
Intermittent swelling
Physical of achilles tendinopathy
Worn shoes
Pain and stiffness 2 to 6 cm above Achilles tendon insertion
Pain with running, especially sprinting
Tenderness over the distal Achilles tendon (2 to 6 cm above the insertion):
Tenderness near insertion suggests insertional Achilles tendinopathy (enthesopathy) or bursitis.
Thickening of distal Achilles tendon in chronic cases
Tenderness with resisted plantar flexion
Weakness with repetitive single leg heel raises
Crepitus with ankle motion
Negative Simmonds-Thompson test: Compression of the calf will cause normal passive plantar flexion of the foot:
A positive test (absence of plantar flexion with calf compression) suggests complete Achilles tendon rupture.
Decreased ankle dorsiflexion (from tight heel cord)
RF of achilles tendinopathy
Training errors: recent increase in distance, intensity, or length of activity
Worn and/or old shoes
Inflexibility, especially tight heel cords
Higher body mass index (BMI)
Hypertension
Diabetes
Hypothyroidism
Older patients: decreased tensile strength and increased stiffness of tendon
Malalignment of the leg (excessive genu valgum, external tibial torsion) or ankle/foot (pes planus)
Medications:
Fluoroquinolones: Recent use of these antibiotics has been associated with increased risk for Achilles tendinopathy and rupture.
Glucocorticoids
Aromatase inhibitors
Statins have been theorized to cause tendinopathy and have been shown in some animal models.
DDx of achilles tendinopathy
Retrocalcaneal bursitis
Superficial Achilles bursitis
Calcaneal apophysitis (Sever condition) in adolescents
Haglund deformity: prominent superior tuberosity of calcaneus
Achilles tendon rupture
Gastrocsoleus tear
Plantaris tendinopathy
Overuse myositis
Chronic exertional compartment syndrome
Os trigonum irritation or posterior ankle impingement syndrome
Vascular/neurogenic claudication
Deep venous thrombosis
Hematoma
Infection
Management of achilles tendinopathy
Relative rest
Consider 7-10 days immobilisation w/ walking boot if sx severe
Ice after activity
Heel lifts short term
Night splints for severe/ refractory sx
Properly fitted shoes
Stretching
Strengthening - gastrocnemius and soleus strengthening program with emphasis on eccentric exercises
NSAIDs
Nitroglycerin patch
¼ patch (1.25mg/ 24hr) can be applied to tendon, replaced q24hr until sx subside
PRP
Surgery
Debridement
If sx persist >6mo w/ conservative treatment
Gradual RTA
No more than 10% increase per week
MOI achilles tendon rupture
Laceration
Pushing off with the weight-bearing forefoot while extending the knee, such as with sprint starts and the push off in basketball
Sudden, unexpected dorsiflexion of the ankle, as when the foot slips in a hole
Violent dorsiflexion of a plantarflexed foot, as with a fall from a height
Sx of achilles tendon rupture
Feeling of being kicked in back of heel
Pop + pain in ankle
Pain in heel
Pain w/ wt bearing
Physical for achilles tendon rupture
Swelling and/ or ecchymosis
Able to walk but not on toes
May still be able to plantar flex but reduced strength
Increased passive dorsiflexion
Unable to do single leg calf raise
Compare resting posture of feet
Positive Thompson test
Palpate for gap
DDx for achilles tendon rupture
Achilles tendinitis
Ankle sprain
Peritendinitis
Retrocalcaneal bursitis
Superficial Achilles bursitis
Periostitis
Plantar tendon rupture
Calcaneal avulsion
Gastroc, soleus or plantaris tear
Achilles tendon rupture pros vs cons of surgery vs nonoperative
RICE
Surgery
Open or percutaneous repair
Lower rate of re-rupture but higher rate of complications
Risks: anesthesia, infection, skin breakdown, scarring, bleeding, accidental nerve injury, blood clots
Non-operative
Higher rate of rerupture (up to 40%), although this is less w/ early mobilisation, but power reduced compared to surgical management
Suitable for elderly, less active patients, poor surgical candidates
RF for achilles tendon rupture
Men >40
Recreational sports
advancing age
Tendinopathy
cortisone injection
systemic corticosteroids
Fluoroquinolones
previous history of tear (esp if managed conservatively as higher risk of re-rupture)
CTD
Immobilization
Obesity
What are the bones in the hind, mid and forefoot?
The hindfoot includes the calcaneus and talus.
The midfoot includes the navicular, cuboid, and cuneiform bones.
The forefoot includes the metatarsals and phalanges
Physical for metatarsal #
Point-tenderness directly over the metatarsal
Mild swelling, bruising
Graduated activity from calf raises to hopping to jogging -> does it reproduce pain?
Single leg hop
Fulcrum test
Imaging for metatarsal #
XR - periosteal reaction to visible # line
CT - To visualise cortical #s in bones
Bone scan - Good at detecting increased bony remodelling, but this is not specific to stress #s. Uptake also remains for a long time so not as useful for ongoing monitoring
MRI - Periosteal or bone marrow edema
DDx for metatarsal #
MTP joint synovitis: inflammation of the joint rather than stress reaction in the bone itself. Bone scan will show distal uptake around MTP joint. MRI is diagnostic. Claw toe may also cause synovitis with plantar displacement of metatarsal head or a metatarsal stress reaction.
MTP capsular strain and/or chip fracture of 1st metatarsal head (turf toe)
Lisfranc sprain/fracture: injury to the 2nd MTC articulation. Any pain at the proximal 2nd metatarsal in association with a twisting injury in plantar flexion should raise concern for this injury.
Midfoot sprain: injury to MTC ligamentous structures
Forefoot mass (ganglion or tumor)
Metatarsalgia
Morton Neuroma
Freiberg infarction: osteonecrosis of 2nd metatarsal head; more common in adolescent athletes with unilateral (usually) pain in 2nd metatarsal head
RF for stress #
> 10 EtOH per week, RED-S, female, low vit D levels, smoking, running >25mi weekly, sudden increase in activity
Intrinsic RF: females, amenorrhea >6mo, low BMD, restricted ROM, RED-S, ED, low vit D
Extrinisic RF: increase in training intensity, duration or frequency, hard surfaces, change in footwear, extremes in age, past hx of stress #
Management of metatarsal stress #
Reduced loading, relative rest, management of contributing factors (optimising bone health, correcting biomechanical errors, using S+C coach, correcting footwear)
Consider exogen
Adjunctive therapies: pulsed US, orthoses, braces, surgery
Calcium 2000mg daily, vit D 1000 units daily, r/o RED-S
Recovery = 12 wks
What is a Dancers # + what is management?
spiral # of 5th metatarsal
Usually non surgical w/ fracture brace or cast shoe
Wt bearing as tolerated
What are the common sites of stress #?
tibia, navicular, fibula, metatarsals, calcaneus
MOI lateral ankle sprain + ligaments injured
Inversion + plantarflexion
Ligaments are injured in sequential pattern
ATFL then CFL then PTFL
RF for lateral ankle sprain
Athletes (especially those involved in sports with jumping near other players and quick “cutting” motions, i.e., basketball, soccer, football)
Dancers
Congenital tarsal coalition (allows less “give” in the foot and results in more stress to ankle)
Prior ankle injury (Previously injured or stretched ligaments provide less overall stability.)
Sx + physical for lateral ankle sprain
Audible pop
Rapid swelling, pain, inability to walk
Physical
Ecchymosis
Swelling
Tenderness to palpate
Anterior drawer:
Tests stability of ATFL; performed by holding the distal tibia and pulling the heel forward. Increased laxity relative to the opposite side indicates a tear of the ATFL. The anterior drawer test in the ankle has poor sensitivity and specificity.
Inversion tilt:
tests stability of CFL; performed by holding the distal tibia and moving the foot from a neutral position to an inversion position. Increased laxity compared with opposite side indicates a tear of the CFL.
Ottawa ankle rules
XR needed if pain in malleolar zone and:
bone tenderness at posterior edge of lateral malleolus OR
bone tenderness at posterior edge of medial malleolus OR
inability to wt bear immediately + in ED
DDx for lateral ankle sprain
Tibia fracture (shaft, malleolus, etc.)
Pilon fracture
Fibula fracture (malleolus, Maisonneuve)
Avulsion fracture
Osteochondral defect in talar dome/tibial plafond
Anterior ankle impingement
Os trigonum syndrome
Talus fracture
Calcaneal fracture
Peroneal subluxation
Bimalleolar/trimalleolar fracture
Management of lateral ankle sprain
RICE, NSAIDS, increase weight bearing as tolerated, bracing/ taping, crutches prn
Consider surgical referral for anatomical reconstruction of Gr III sprain after 6 weeks of conservative management
Complications of lateral ankle sprain
Stiffness from prolonged immobilization
Recurrent instability
Osteochondral defects
Chronic regional pain syndromes
Describe the lateral ankle ligaments
Anterior talofibular ligament (ATFL): passes from the tip of the fibula to the lateral talar neck; taut in plantar flexion; injured most commonly
Calcaneofibular ligament (CFL): passes inferior and posterior from the tip of the fibula to the lateral calcaneus; usually injured with the ATFL
Posterior talofibular ligament (PTFL): passes posteriorly from the fibula to the talus; injured less often
What ligament is injured in a medial ankle sprain?
Deltoid
RF medial ankle sprain
Previous ankle sprain
High-risk sports, including football, basketball, and long jumping
Valgus-flat foot deformity
Low arch of the foot (i.e., pes planus)
Dysfunction of the spring ligament
Dysfunction of the posterior tibialis
Extreme fatigue of peroneus (fibularis) longus muscle
MOI medial ankle sprain
Off-balanced, pronated foot landing, which leads to forced external rotation, abduction, and eversion
Supination and excessive external rotation of the ankle
Sx + physical for medial ankle sprain
Medial ankle pain
Swelling + ecchymosis
Physical
Tenderness over deltoid
A check of posterior tibial tendon function with resisted inversion.
A check of extensor hallucis longus tendon function with resisted extension of the great toe.
A check of range of motion of the ankle joint.
A check of flexor hallucis longus tendon function with resisted flexion of the great toe.
An eversion stress test determines the stability of the deltoid ligament; this is done with passive eversion of the ankle
An anterior drawer test may evaluate anterior and medial subluxation with deltoid ligament injury
DDx for medial ankle sprain
Syndesmosis tear or sprain
Posterior tibial tendon tear or subluxation
Flexor hallucis longus tendon tear or sprain
Distal tibia fracture
Osteochondral fracture of the talar dome
Fracture of the calcaneus
Fracture of the lateral process of the talus
Medial ankle sprain with associated proximal fibular fracture (Maisonneuve fracture
Management medial ankle sprain
PRICE
Aircast boot, limit wt bearing
Grade I sprain:
functional rehabilitation and possibly a splint or a brace, with the recognition that return to sports generally is more delayed (3 to 6 wk) than with a lateral sprain (1 to 3 wk)
Grade II sprain
same as grade 1, but in addition, may need a short period prior of immobilization in posterior splint or walking boot (3 to 4 wk)
Grade III sprain
Treatment is controversial; requires immobilization (6 to 8 wk) or may need operative repair
Refer for surgery if:
Significant instability
Grade 3 injury
Rehab for medial ankle sprain
The exercises should begin as soon as the initial pain and swelling have subsided sufficiently to allow the patient to perform simple exercises and should continue until the patient has returned to pain-free activity
Achilles tendon stretch
Foot circles
Alphabet exercises: Although leg is stable, patient should use the great toe and foot to “write” the letters of the alphabet in the air.
Isometric and isotonic plantar flexion, dorsiflexion, inversion, eversion, and toe curls
Marble pickups (using toes)
Heel walks
Toe walks
Circular wobble board
Walking on different surfaces
Walk–jog, jog–run
What is a Jones #?
base of 5th metatarsal at metaphyseal-diaphyseal junction
Management of Jones #
Rx
RICE
Immobilisation w/ aircast + crutches x6-8wks
NSAIDs
Consider Exogen
Calcium + vit D
Surgery if displaced, not responding to conservative management
RTP quicker
More reliable rehab
Intramedullary screw fixation, may need bone grafting
Immobilised in cast x2 wks
Sx + physical for navicular #
Insidious onset, poorly localised midfoot ache
Pain radiates along medial arch dorsally
Improves w/ rest
Physical
Localised tenderness at “N spot” - proximal dorsal navicular
Minimal swelling
Management of navicular #
Non wt bearing w/ cast or removable brace x8 wks
Mobilise stiff ankle, subtalar, midtarsal joints + calf
Recovery - 4mo
Rehab/ FU for navicular #
Cast x8 wks
Reexamine patient every 2 to 3 wk to ensure adequate recovery.
8-10 wks: activities of daily living, swimming, water running
10-12 wks: Assess “N” spot; if nontender, then 5-min jogging on grass every other day. Gradually increase to 10 min per session.
12-14 wks: Assess “N” spot; if nontender, then faster running for short distances, that is, 50 m on alternate days; gradual speed increase
14-16 wks: Assess “N” spot; if nontender, then gradual return to full training over several weeks. Average time to return to sport is 5 to 6 mo from diagnosis.
RF for navicular #
Training errors: number, frequency, intensity, and duration of strain cycles
Impact attenuation: muscle fatigue, training surfaces, footwear
Gait mechanics: foot type, lower extremity alignment, altered gait
Bone health: nutrition, genetics, hormones, bone disease
Sprinting, jumping, hurdling
Ballet
Ottawa foot rules
XR needed if pain in midfoot zone and:
bone tenderness at base of 5th metatarsal OR
bone tenderness at navicular OR
inability to wt bear immediately + in ED
What is a syndesmosis injury?
Injury to:
anterior inferior tibiofibular ligament (AITFL)
posterior inferior tibiofibular ligament (PITFL)
interossseous ligament (IOL)
interosseous membrane (IOM)
MOI syndesmosis injury
Sudden, forced external rotation + hyperdorsiflexion of ankle
Soccer (player tackling ball), football (player prone, has foot stepped on, leading to forceful external rotation), and skiing (slalom skiers, catch ski on gate)
RF sports syndesmosis injury
Collision sports are at higher risk:
Football
Rugby
Lacrosse
Sports that immobilize the foot in a high ankle shoe or boot:
Hockey
Slalom skiing; catching inner ski on gate
Wrestling
Sports played on turf (e.g., soccer)
Sx syndesmosis injury
Usually report inversion mechanism
“Regular” ankle sprain that isn’t improving
Pain usually between anterior distal tibia and fibula and also posteromedially at ankle joint.
Pain can be persistent on weight-bearing or an unusually long period of recovery after the initial injury.
Pain is also worse with pushing off or with external rotation.
Physical for syndesmosis injury
Dorsiflex + plantarflex talus to find joint line
Palpation over syndesmosis is painful
Usually minimal swelling
Squeeze test at mid calf causes pain at ankle
External rotation test: distal lower leg is stabilized with ankle in neutral position while mediolateral force/external rotation of the foot is performed; positive test noted by pain and/or increased rotation relative to unaffected side
Push-off test: Push off/heel raise on affected side may be weak or absent.
Fibular translation (drawer) test: pain or increased translation of fibula from anterior to posterior or loss of firm end point relative to uninjured side
Stabilization test: Distal syndesmosis is stabilized with athletic tape and assess if symptoms are decreased with running and jumping.
Cotton test: increased translation or pain with translation of talus from medial to lateral (may indicate deltoid ligament tear)
Crossed-leg test: pain at syndesmosis with gentle pressure exerted on the medial side of the knee while resting the midtibia of affected leg on uninjured knee
Ix for syndesmosis injury
XR
normally fibular overlaps tibia - can see widening of this
Stress view for XRs (dorsiflexion then external rotation)
MRI
DDx for syndesmosis injury
PER ankle fracture (Weber C)
SER ankle fracture (Weber B)
Fracture of the proximal fibula (Maisonneuve)
Ossification of the syndesmosis
Calcification of the syndesmosis
Deltoid ligament tear
Talar dome fracture
Management + RTP of syndesmosis injury w/o #
NSAIDs, ice, rest, elevation, compression
Non wt bearing in cast/ boot x2 wks
Then high ankle brace + ROM exercises, then progress to strengthening
RTP 6 to 8 wk
Management of syndesmosis injury with fracture
Refer for surgery (screw fixation)
Non wt bearing cast x6 wks
Sx of plantar fasciitis
Insidious + progressive pain in inferior heel
Can be bilateral
Worse in AM with first few steps
Lessens w/ gradually increased activity
Worsens w/ prolonged standing or inactivity
Physical for plantar fasciitis
Tenderness localized to anteromedial aspect of the heel with palpation
Tight Achilles heel cord
Pes planus or pes cavus foot deformity
Passive range of motion: hypermobility of subtalar joint, midtarsal joint, and first ray
Pain with passive dorsiflexion of toes
DDx for plantar fasciitis
Skeletal:
Calcaneal stress fracture
Bone contusion
Subtalar arthritis
Inflammatory arthropathies
Infections (osteomyelitis/subtalar pyarthrosis)
Neoplasm
Soft tissue:
Intrinsic muscle strain (abductor hallucis, flexor digitorum brevis, quadratus plantae)
Plantar fibromatosis
Plantar fascia rupture
Achilles tendinitis
Posterior tibial tendinitis
Retrocalcaneal bursitis
Fat pad atrophy
Neurologic:
Entrapment of branches of the posterior tibial nerve usually at or after passage through the posterior tarsal tunnel: medial plantar nerve, lateral plantar nerve, or medial calcaneal nerve
Radicular symptoms of L4–S1 (sciatic nerve)
Abductor digiti quinti nerve entrapment
Peripheral neuropathy
Management of plantar fasciitis
Avoid aggravating activity
Avoid barefoot walking + flat shoes
Stretching in morning + throughout day
High load eccentric strength training
RICE
NSAIDs
Taping foot (arch taping)
Comfortable shoes
Night splint - toes in extension, ankle at 90 degrees
Extremes - orthotics, steroids, surgery
RF for plantar fasciitis
Excessive torsion and hyperpronation with poor supporting footwear
Poor shock dissipation with cavus foot
Hindfoot valgus with pronation deformity
Limited ankle dorsiflexion
Varus knee alignment in runners
Obesity and prolonged standing on hard surfaces
Spiked athletic shoes
What is a hallux valgus?
Hallux valgus (HV) refers to a subluxation of the 1st metatarsophalangeal (MTP) joint with lateral or valgus deviation of the great toe and medial or varus deviation of the 1st metatarsal, leading to a bony prominence at the medial aspect of the joint (medial eminence or bunion
RF for hallux valgus
Fam hx
Constrictive footwear
Females
Sx + physical for hallux valgus
Pain over medial MTP prominence
Physical
Assess severity standing + non wt bearing
Check alignment of arch + hindfoot
Management of hallux valgus
Wider toe box footwear
Shoes w/ flexible stitching over medial eminence
Medial longitudinal arch support
Surgery if above failed (osteotomy, MTP fusion if severe)
Complications of surgery::
Stiffness
Decreased ROM
Bunion may persist
What is a hammer, claw + mallet toe?
Mallet toe is a flexion deformity at the distal interphalangeal (DIP) joint.
Hammer toe is a flexion deformity affecting the proximal interphalangeal (PIP) joint. Concomitant extension at the MTP joint may be present.
Claw toe is a flexion deformity affecting the PIP and DIP joints. Concomitant extension at the MTP joint is always present.
RF for hammer/ claw/ mallet toe
Increasing age
Constrictive footwear
Neuromuscular disorders (peripheral neuropathy, muscular dystrophy, stroke, CP)
Obesity
Management of hammer/ claw/ mallet toe
Shoes - wider toe box, flat/ low feel
Orthotics
Pressure relief methods:
Toe sleeves, typically with foam padding to relieve pressure over the dorsal toe
Toe crests relieve pressure at the tip of the toes.
Metatarsal pads relieve pressure under the metatarsal heads.
Rocker bottom sole can help reduce forefoot pressure during gait
Surgery may be indicated if non operative treatment is unsuccessful
Botox if clawing is d/t spasticity
What is Morton’s neuroma?
An inflammatory fibrosing process of the interdigital nerve of the foot, characterized by pain on the plantar surface of the foot
Most commonly occurs between the heads of the 3rd and 4th metatarsals, although may also involve the 2nd or 4th intermetatarsal spaces
RF Morton’s neuroma
Females
Kickboxers, ballet dancers, runner
Sx of Morton’s neuroma
Intermittent, episodic pain, usually on the plantar surface of the foot between the 3rd and 4th metatarsals
Forefoot pain radiating to the affected interspace and toes
Numbness or paresthesias in the toes and interdigital space are common
Pain on weight-bearing, exacerbated with exercise, and relieved with rest
Physical of Morton’s neuroma
Tenderness to palpation on the plantar surface of the foot, usually between the 3rd and 4th metatarsals
Mulder click: compress metatarsals together laterally, pain or click in between metatarsals is positive finding
DDx for Morton’s neuroma
Metatarsalgia
Metatarsal stress fracture
Ganglion cyst
Neuropathies (diabetic, alcoholic, toxic, nutritional)
Intermetatarsal bursitis
Freiberg disease (metatarsal avascular necrosis)
Management of Morton’s neuroma
Decreased pressure on metatarsal heads
Wide toe box shoes
Metatarsal pad
Avoid repetitive toe dorsiflexion
NSAIDs
Steroid inj
Surgical excision of neuroma is indicated if conservative therapy fails
What is turf toe, MOI + RF
1st MTP sprain
MOI
Forced hyperextension of 1st MTP causing a sprain
RF
Artificial turf and playing surfaces
Athlete’s experience and years of sports participation
Athlete’s position while playing sport
Athlete’s weight, where higher forces are transmitted with increased weight
Flattening of the 1st MTP
Football players (defensive and offensive running backs, wide receivers, linemen)
Foot pronation
Hallux degenerative joint disease
Increased ankle dorsiflexion
Increased friction between athletic shoe and turf
Increased toe box flexibility and decreased number of cleats in the shoe
Prior 1st MTP joint injury
Pes planus
Sx 1st MTP sprain
Pain w/ wt bearing
Pain w/ ROM
Pain w/ applied pressure to MTP during running or jumping (toeing off)
Swelling
Physical for 1st MTP sprain
DDx for 1st MTP sprain
Gout
Plantar plate rupture
1st distal metatarsal or proximal phalangeal fracture
Osteoarthritis of 1st MTP (hallux rigidus)
Sesamoiditis
Sesamoid stress fracture
Management of 1st MTP sprain
Grade 1
Ice, NSAIDs, elevation
Toe taping to restrict excessive dorsiflexion
Gentle ROM exercises from day 5
Grade 2
As grade 1 but include orthotics
Explosive, push off activities should be restricted until pain free, usually x2 wks
Grade 3
As grade 2 but restriction of activity likely up to 8 wks
Name of rehab protocol + details of protocol for achilles tendon rupture
Fowler Kennedy
0-2wks: aircast boot, 2cm heel lift, NWB w. crutches
2-6wks: aircast boot w/ 2cm heel lift, protected wt bearing w/ crutches. Active ROM. Knee + hip exercises as appropriate, hydrotherapy
6-8 wks: aircast boot, d/c heel lift, WBAT. Dorsiflexion stretching, graduated resistance exercises, gait training
8-12 wks: wean off boot, progress ROM, strength + proprioception
>12 wks: increase dynamic WB exercise, plyometric training, sports specific training
