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6 Orthopedics > L15 Achilles and Syndesmosis > Flashcards

L15 Achilles and Syndesmosis Flashcards

1
Q

Tendon Anatomy

A

dense, fibrous connective tissue
has tenocytes, type 1 collagen, proteoglycans

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2
Q

Proteoglycans

A

organize and lubricate collagen fiber bundles

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3
Q

Tenocytes

A

low rates of proliferation

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4
Q

Type 1 collagen

A

makes extracellular matrix
provides elasticity
responsive to changes in mech load

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5
Q

Tendon biomechanical principles

A

-time dependent viscoelastic properties
-speed matters
-higher CSA and shorter length, causing stiffness
-responds to loading on a bell curve

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6
Q

Decreased strength and stiff tendon

A

low strain tolerance

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7
Q

Higher strength and more compliance

A

more strain tolerance

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8
Q

Tendon loading types

A

compressive (hamstring)
shear and friction (achilles)
tensile
combinations (hamstring)

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9
Q

Tendinopathies account for

A

30-50% of all sports related injuries

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10
Q

Pathoanatomy of Tendons

A

theories include collagen disruption/tearing, inflammation, tendon cell response

increased proteoglycan content, water, type 3 collagen causes disorganized collagen within tendon

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11
Q

Tendinopathy

A

preferred term for persistent achilles tendon pain and loss of functionT

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12
Q

Tendonitis

A

transient and usually dissipates 2-3 days after event

not the primary driver

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13
Q

Tendinosis

A

degeneration without clinical or histological signs of inflammatory response

collagen degeneration with fiber disorganization

neovascularization but poor at nutrient and oxygen transport

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14
Q

Paratennitis

A

acute inflammation of the sheath

tendon rubs over bony protuberance causing edema. Fibrinous exudate fills sheath creating crepitus squeak, and causes tendon to become thicker

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15
Q

Tendon Healing

A

same three over-lapping phases as other tissues (hemostasis, cellular proliferation, long-term remodeling)

generally 12-16 weeks before tendon ca be appropriately stressed, can take 40-50 weeks for it regain normal tensile strength

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16
Q

What complicates tendon healing

A

vascularity
excessive adhesions
early or excessive activity

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17
Q

Achilles TEndon overview

A

passive and relative inelastic tissue that stores and transfers force

ability to deform just enough to absorb and store energy allows them to release energy when needed

critical for locomotion, balance, posture

can experience 5-6% strain and 4-8x bodyweight GRF during walking, running

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18
Q

Why is achilles critical for locomotion?

A

has 70% maximal available torque capability required for normal push off phase of walking

may explain why moderate weakness can cause significant gait disturbances

injury, post op rehab or disuse atrophy with aging can cause weakness

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19
Q

Pathophysiology of Achilles Tendonosis

A

decreased vascular volume 3-6 cm above insertion leads to avascularity which leads to tendinosis

increased tenocyte response and local disorganization of tendon structure

tendinosis may be present rather than any inflammatory processes

amount of tendon tissue disorganization is NOT directly correlated to pain

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20
Q

Tendon anatomy changes do NOT equate to

A

pain severity or disability levels

often high prevalence of tendon patho in asymptomatic male runners

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21
Q

Achilles TEndinopathy RF

A

Intrinsic = age 30-40, men, genetics

Extrinsic = poor technique, training errors, footwear, endocrine, high BMI

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22
Q

Possible biomechanical faults for achilles tendinopathy

A

overpronation
high arch
dynamic pes planus
gastroc/soleus weakness
excessive rotary forces on tibia
hip weakness or loss of ROM
hindfoot varus deformity
STJT hypomobility
compensation of hip/knee flex in gait

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23
Q

Os Trigonum

A

common accessory bone present in 20% of population but rarely symptomatic

can become dislodged and create impingement-type pain, esp with excessive PF loads

becomes asymptomatic over time, not need for surgery

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24
Q

Calcaneal Bursitis

A

pain worse with activity, not after inactivity

superficial posterior or deep posterior but no pain along tendon

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25
Q

Treatment for calcaneal Bursitis

A

footwear mod in short term
heel cups in short term
ice prn for pain
activity mod
look for potential kinetic chain

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26
Q

Exam for Achilles Tendinopahty

A

establish baselines for loading; figure out what they can tolerate during and afterwards

look for concomitant ankle/foot joint and soft tissue mobility restrictions

does the bulge move, midportion is more common than insertional

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27
Q

Prognosis for achilles tendinopathy

A

favorable, long-term prognosis for acute to subcronic AT with nonoperative treatment

6 to 12 weeks of intervention shows decrease in pain and improvement in function

85% of athletes RTS

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28
Q

Gait Alterations in AT

A

increased eversion ROM of rearfoot
reduced ankle DF velocity
reduced knee flexion excursion
altered plantar pressures
delayed tib an activation
increased calf activity
excessive midfoot pronation

reduced glute med and rectus femor prior to foot strike

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29
Q

Short Term Phase 1 management of AT

A

heel lift
alt aerobic exercise
patient ed
manual therapy
ther ex
gait retraining
modalities

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30
Q

Short Term Phase 2

A

progressive ther ex
gait retraining
weaning from external supports

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31
Q

AT Exercise Progression

A

(isometric exercises)
Isotonic Exercises 4x15
Add weights 4x6
Plyometric exercises
gradual return to sports

changing stages has to be less than 5/10 pain

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32
Q

Why does tendon loading work?

A

increase load tolerance through mechanotransduction

movement stimulates the extra-cellular matrix changes

you need more than isometrics to change the baseline of mechanoreceptors transduction

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33
Q

Goals of tendon loading

A

increase tendon stiffness and resistance to strain

increased tendon and muscle cross sectional area

1 RM

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34
Q

Tendon Loading Principles

A

start with what they can tolerate and perform well

magnitude: 4-6% strain
intensity: heavy load
duration: 12-14 weeks
frequency: 7x week to 2-3 x week
Speed: slower for cellular changes

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35
Q

Tendon Rehab Principles

A

early education
frequent check ins
patient pain during and afternoon

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36
Q

Achilles Tendinopathy Rehab Phase 1

A

symptom management and load reduction

wk 1 to 2, patient has pain and difficulty with all activities

goal = start to exercise and understand nature of injury and how to use pain-monitoring model

treatment = once a day, includes heel rises and circulation like moving ankle in a circle

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37
Q

AT Rehab Phase 2

A

recovery phase

wk 2 to 5, pt has pain with exercise, morning stiffness, pain with heel rises

goals: start strengthening

treatment = once a day, heel rises over edge of step, quick rebounding heel rises

38
Q

AT Rehab Phase 3

A

rebuilding phase

wk 3-12, patient tolerates recovery phase, no pain at insertion, morning pain

goal = heavier strength training, increase or start running/jumping

tx = one leg heel rises, plyometrics, weights

39
Q

AT Rehab Phase 4

A

return to sports phase

3 to 6 mo, pt has minimal symptoms, can participate in sports

goals: maintain exercise with no symptoms

tx: 2 to 3x a week. one leg heel rises with weight, eccentric, etc

40
Q

pts with AT may benefit from

A

decrease in overall repetitions and an increase in weight/load

41
Q

Does high load mean more pain?

A

there is a low correlation between pain and loading

42
Q

Manual therapy for AT

A

helps to improve joint and soft tissue mob but should be tapered down asap

should be adjunctive to exercise and education

use both soft tissue mob and joint mob

43
Q

How to improve pain with AT

A

improve self efficacy and education patients to build self-management skills is more important than specific educational approaches

44
Q

Insertional Achilles Tendinopathy

A

1/3 AT will have insertional IT

not solved by shaving off bone

combination of tensile and compressive load issue

typically idiopathic and can be asymptomatic, longer recovery times

45
Q

Predisposing factors to insertional AT

A

genetics/hereditary
pes cavus/high arches
tight achilles tendon
lateral WB through heel
BMI
improper/tight shoes
over-training

46
Q

surgery for insertional AT

A

considered only after > 6 months of active treatment without recovery

47
Q

What is not recommended for IAT?

A

night splints
steroid injections
PRP

48
Q

Achilles Tendon Rupture

A

most common complete tear
peak at 3 to 5th decade
10% reported s/s before rupture
>70% have tendinosis prior

49
Q

Increasing incidence of AT rupture due to

A

sport participation later in life
metabolic disease

50
Q

MOI of ATR

A

usually during traumatic sporting event

rapid df during forceful pf, eccentric overload

51
Q

Patient history of ATR

A

reports pop, sniper shot from behind
immediately disabling

52
Q

RF for ATR

A

metabolic diseases
immunosuppressive therapy
neurovascular disease
training

53
Q

Exam of Achilles Rupture

A
  1. visible and/or palpable defect
  2. increased resting ankle DF in prone
  3. marked weakness with ankle PF
  4. increased passive df with abnormal end feel
    • thompson test
54
Q

Acute management of ATR

A

refer to surgeon
NWB with crutches
immobilized with pf boot for 4 wks
modalities for pain/inflammation
avoid stretching
watch for DVT

55
Q

Controversy for ATR, surgery vs non-operative

A

incidence of re-rupture and DVT is similar

both have risk of tendon lengthening

surgery runs the risk of infection, sural nerve injury, adhesions

conservative and surgical are equivalent in treatment options

56
Q

Indications for non-operative ATR

A

rupture diagnosed and immob <72hr
mid portion tear <10 mm
patient goals post injury

57
Q

Progressive early mob protocol, ATR

A
  1. early WB in boot with progessive PF to neutral
  2. WB is distributed through heel not forefoot
  3. After 2 weeks, AROM to full PF with DF
  4. Global strengthening

has a low re-rupture rate

58
Q

2-4 weeks Progressive early mob protocol

A

ARROM starting with isometrics to light band

59
Q

4-5 wks Progressive early mob protocol

A

increase tband resistance and add seated heel raises

60
Q

6 weeks Progressive early mob protocol

A

wean out of boot, gait and balance training

61
Q

6-8 weeks Progressive early mob protocol

A

introduce standing heel raises with asymmetrical WB to symmetric

62
Q

12 weeks Progressive early mob protocol

A

expect that 50% of pts can perform a unilateral heel raise

63
Q

Post op rehab for ATR

A

6 weeks NWB in boot to then PWB

recently progressive protocol that suggests WB in boot within 2 weeks and preogress to neutral DF in 4-6 weeks

should address scar adhesions, gentle isometrics pf in boot

64
Q

Things that prevent ATR RTS

A

Fear of reinjury
Weakness
inability as professional

65
Q

Contributing factors to poor outcomes for ATR

A

tendon elongation
collagen doesn’t convert from 3 to 1
surgical technique
patient compliance
co-morbidities
improper loading program

66
Q

AT changes after rupture repair

A

tendon gap visible up to 12 wks
thicker tendon (10 mm)
high vascularity
tendon calcifications
adhesions

67
Q

Key rehab principles for ATR

A

it can’t be tightened after elongated
don’t forget kinetic chain
go slow progressing load
progress load before speed
walk fast before slow jog
don’t go for symmetry

68
Q

Markers for ATR progress

A

seated SL heel raise at 50% BW
gait pattern
Standing SL heel raise at 100% BW
decreased fear, increased confidence

69
Q

MOI for high ankle sprains

A

planted foot, er of foot forces the talus to rotate laterlly, pushing fibula away from tibia, tibia rotates internally

external contact is common

70
Q

High ankle sprain involves

A

AITFL, PITFL, interossesous membrane, malleolar fracture, proximal fibular spiral fracture

71
Q

S/S of high ankle sprain

A

anterolateral ankle pain
pain is superior from L. malleolus
difficulty WB
maybe m. ankle tenderness
not a ton of swelling

72
Q

Exam of high ankle sprain

A

palpation of AITFL and PITFL, medial/lateral malleoli, all along fibula

df lunge test

73
Q

Prognosis of high ankle sprain

A

if missed, may lead to arthritis

usually prolonged and variable recovery and may extend twice that of standard ankle sprain

excellent functional outcomes if syndesmosis is reduced

74
Q

What grade of ankle sprain is the hardest to help?

A

grade 2, whether stable or unstable

75
Q

Sprain without diastasis tx

A

WBAT

76
Q

Sprain with diastasis tx

A

NWB in boot for 4-6 weeks

77
Q

General tx for high ankle sprain

A

radiographs in mortise view to check WB before RTS

bracing

caution with excessive DF in WB, full weight bearing and sports will have the most DF

78
Q

Low ligaments of ankle

A

post talofibular ligament
anterior talofibular ligament
calcaneofibular ligament

79
Q

High ligaments of ankle

A

posterior tibiofibular ligament
anterior tibiofibular ligament

80
Q

Epidemiology of acute lateral ankle

A

12-17
associated with higher rates of ankle sprain, 1/2 patients report ankle sprains

most occur during sports like basketball, football, soccer

moderate rate of reinjury

81
Q

RF for Lateral Ankle Sprains

A

-poor performance multiple hop test
-poor performance on star excursion balance test
-decreased hip abductor and extensor strength
-female
-court sports

common impairment is limited DF

82
Q

Complications of acute lateral ankle sprain

A

avulsion fx of distal fibula
bone bruising
higher likelihood of OA
fibularis tendinopathy
chronic instability
ROM deficits

83
Q

Treatment for lateral ankle disorders

A

RICE alone is not recommended as stand-alone intervention plan for acute

bracing
balance (SLS, Y balance)
function (step down, hop)

84
Q

Bracing for lateral ankle disorders

A

-prophylatic bracing is recommended to prevent them in higher risk sports and individuals
-bracing as a transition from immobilization boot/cast is recommended
-taping can be as effective but not as long term cost effective

85
Q

Prognosis for lateral ankle sprain

A

1-2 weeks for return to work and sport for mild sprains

6-8 weeks for return to work and sport severe sprains

up to 20% may develop CAI

86
Q

Chronic Ankle Instability

A

Recurrent episodes of ankle sprains and/or continud functional limitations for >1 yr

87
Q

Possible mechanisms for CAI

A

excessive soft tissue laxity
peroneal nerve injury
decreased INV/EVE
impaired proprioception

88
Q

Predictive Factors for CAI

A

inability to jump/land 2 weeks after 1st injury

poor dynamic postural control

higher self reported disability scores

Y test score asymmetry >3 cm

89
Q

Surgical for CAI

A

brostrom repair = suturing w/anchors of ATFL and CFL. Can also include extensor retinaculum

good outcomes for >60 years

2 weeks NWB in boot, limit ankle inversion for 10 weeks, return to sport at 12-16 weeks

90
Q

Reverse anterolateral drawer test

A

may be superior test because patients relax more and maintenance of proper translation plane is easier

91
Q

Talar Tilt stress test

A

tests the CF ligament
moving into inversion to assess for pain and end feel

92
Q

Eversion Talar Stress TEst

A

testing the deltoid ligament
done in inversion, comparing movement and pain

6 Orthopedics (17 decks)

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