L15 Achilles and Syndesmosis Flashcards
Tendon Anatomy
dense, fibrous connective tissue
has tenocytes, type 1 collagen, proteoglycans
Proteoglycans
organize and lubricate collagen fiber bundles
Tenocytes
low rates of proliferation
Type 1 collagen
makes extracellular matrix
provides elasticity
responsive to changes in mech load
Tendon biomechanical principles
-time dependent viscoelastic properties
-speed matters
-higher CSA and shorter length, causing stiffness
-responds to loading on a bell curve
Decreased strength and stiff tendon
low strain tolerance
Higher strength and more compliance
more strain tolerance
Tendon loading types
compressive (hamstring)
shear and friction (achilles)
tensile
combinations (hamstring)
Tendinopathies account for
30-50% of all sports related injuries
Pathoanatomy of Tendons
theories include collagen disruption/tearing, inflammation, tendon cell response
increased proteoglycan content, water, type 3 collagen causes disorganized collagen within tendon
Tendinopathy
preferred term for persistent achilles tendon pain and loss of functionT
Tendonitis
transient and usually dissipates 2-3 days after event
not the primary driver
Tendinosis
degeneration without clinical or histological signs of inflammatory response
collagen degeneration with fiber disorganization
neovascularization but poor at nutrient and oxygen transport
Paratennitis
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
Tendon Healing
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
What complicates tendon healing
vascularity
excessive adhesions
early or excessive activity
Achilles TEndon overview
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
Why is achilles critical for locomotion?
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
Pathophysiology of Achilles Tendonosis
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
Tendon anatomy changes do NOT equate to
pain severity or disability levels
often high prevalence of tendon patho in asymptomatic male runners
Achilles TEndinopathy RF
Intrinsic = age 30-40, men, genetics
Extrinsic = poor technique, training errors, footwear, endocrine, high BMI
Possible biomechanical faults for achilles tendinopathy
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
Os Trigonum
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
Calcaneal Bursitis
pain worse with activity, not after inactivity
superficial posterior or deep posterior but no pain along tendon
Treatment for calcaneal Bursitis
footwear mod in short term
heel cups in short term
ice prn for pain
activity mod
look for potential kinetic chain
Exam for Achilles Tendinopahty
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
Prognosis for achilles tendinopathy
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
Gait Alterations in AT
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
Short Term Phase 1 management of AT
heel lift
alt aerobic exercise
patient ed
manual therapy
ther ex
gait retraining
modalities
Short Term Phase 2
progressive ther ex
gait retraining
weaning from external supports
AT Exercise Progression
(isometric exercises)
Isotonic Exercises 4x15
Add weights 4x6
Plyometric exercises
gradual return to sports
changing stages has to be less than 5/10 pain
Why does tendon loading work?
increase load tolerance through mechanotransduction
movement stimulates the extra-cellular matrix changes
you need more than isometrics to change the baseline of mechanoreceptors transduction
Goals of tendon loading
increase tendon stiffness and resistance to strain
increased tendon and muscle cross sectional area
1 RM
Tendon Loading Principles
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
Tendon Rehab Principles
early education
frequent check ins
patient pain during and afternoon
Achilles Tendinopathy Rehab Phase 1
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
AT Rehab Phase 2
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
AT Rehab Phase 3
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
AT Rehab Phase 4
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
pts with AT may benefit from
decrease in overall repetitions and an increase in weight/load
Does high load mean more pain?
there is a low correlation between pain and loading
Manual therapy for AT
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
How to improve pain with AT
improve self efficacy and education patients to build self-management skills is more important than specific educational approaches
Insertional Achilles Tendinopathy
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
Predisposing factors to insertional AT
genetics/hereditary
pes cavus/high arches
tight achilles tendon
lateral WB through heel
BMI
improper/tight shoes
over-training
surgery for insertional AT
considered only after > 6 months of active treatment without recovery
What is not recommended for IAT?
night splints
steroid injections
PRP
Achilles Tendon Rupture
most common complete tear
peak at 3 to 5th decade
10% reported s/s before rupture
>70% have tendinosis prior
Increasing incidence of AT rupture due to
sport participation later in life
metabolic disease
MOI of ATR
usually during traumatic sporting event
rapid df during forceful pf, eccentric overload
Patient history of ATR
reports pop, sniper shot from behind
immediately disabling
RF for ATR
metabolic diseases
immunosuppressive therapy
neurovascular disease
training
Exam of Achilles Rupture
- visible and/or palpable defect
- increased resting ankle DF in prone
- marked weakness with ankle PF
- increased passive df with abnormal end feel
- thompson test
Acute management of ATR
refer to surgeon
NWB with crutches
immobilized with pf boot for 4 wks
modalities for pain/inflammation
avoid stretching
watch for DVT
Controversy for ATR, surgery vs non-operative
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
Indications for non-operative ATR
rupture diagnosed and immob <72hr
mid portion tear <10 mm
patient goals post injury
Progressive early mob protocol, ATR
- early WB in boot with progessive PF to neutral
- WB is distributed through heel not forefoot
- After 2 weeks, AROM to full PF with DF
- Global strengthening
has a low re-rupture rate
2-4 weeks Progressive early mob protocol
ARROM starting with isometrics to light band
4-5 wks Progressive early mob protocol
increase tband resistance and add seated heel raises
6 weeks Progressive early mob protocol
wean out of boot, gait and balance training
6-8 weeks Progressive early mob protocol
introduce standing heel raises with asymmetrical WB to symmetric
12 weeks Progressive early mob protocol
expect that 50% of pts can perform a unilateral heel raise
Post op rehab for ATR
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
Things that prevent ATR RTS
Fear of reinjury
Weakness
inability as professional
Contributing factors to poor outcomes for ATR
tendon elongation
collagen doesn’t convert from 3 to 1
surgical technique
patient compliance
co-morbidities
improper loading program
AT changes after rupture repair
tendon gap visible up to 12 wks
thicker tendon (10 mm)
high vascularity
tendon calcifications
adhesions
Key rehab principles for ATR
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
Markers for ATR progress
seated SL heel raise at 50% BW
gait pattern
Standing SL heel raise at 100% BW
decreased fear, increased confidence
MOI for high ankle sprains
planted foot, er of foot forces the talus to rotate laterlly, pushing fibula away from tibia, tibia rotates internally
external contact is common
High ankle sprain involves
AITFL, PITFL, interossesous membrane, malleolar fracture, proximal fibular spiral fracture
S/S of high ankle sprain
anterolateral ankle pain
pain is superior from L. malleolus
difficulty WB
maybe m. ankle tenderness
not a ton of swelling
Exam of high ankle sprain
palpation of AITFL and PITFL, medial/lateral malleoli, all along fibula
df lunge test
Prognosis of high ankle sprain
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
What grade of ankle sprain is the hardest to help?
grade 2, whether stable or unstable
Sprain without diastasis tx
WBAT
Sprain with diastasis tx
NWB in boot for 4-6 weeks
General tx for high ankle sprain
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
Low ligaments of ankle
post talofibular ligament
anterior talofibular ligament
calcaneofibular ligament
High ligaments of ankle
posterior tibiofibular ligament
anterior tibiofibular ligament
Epidemiology of acute lateral ankle
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
RF for Lateral Ankle Sprains
-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
Complications of acute lateral ankle sprain
avulsion fx of distal fibula
bone bruising
higher likelihood of OA
fibularis tendinopathy
chronic instability
ROM deficits
Treatment for lateral ankle disorders
RICE alone is not recommended as stand-alone intervention plan for acute
bracing
balance (SLS, Y balance)
function (step down, hop)
Bracing for lateral ankle disorders
-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
Prognosis for lateral ankle sprain
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
Chronic Ankle Instability
Recurrent episodes of ankle sprains and/or continud functional limitations for >1 yr
Possible mechanisms for CAI
excessive soft tissue laxity
peroneal nerve injury
decreased INV/EVE
impaired proprioception
Predictive Factors for CAI
inability to jump/land 2 weeks after 1st injury
poor dynamic postural control
higher self reported disability scores
Y test score asymmetry >3 cm
Surgical for CAI
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
Reverse anterolateral drawer test
may be superior test because patients relax more and maintenance of proper translation plane is easier
Talar Tilt stress test
tests the CF ligament
moving into inversion to assess for pain and end feel
Eversion Talar Stress TEst
testing the deltoid ligament
done in inversion, comparing movement and pain
