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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
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
26
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
27
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
28
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
29
Short Term Phase 1 management of AT
heel lift alt aerobic exercise patient ed manual therapy ther ex gait retraining modalities
30
Short Term Phase 2
progressive ther ex gait retraining weaning from external supports
31
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
32
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
33
Goals of tendon loading
increase tendon stiffness and resistance to strain increased tendon and muscle cross sectional area 1 RM
34
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
35
Tendon Rehab Principles
early education frequent check ins patient pain during and afternoon
36
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
37
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
38
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
39
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
40
pts with AT may benefit from
decrease in overall repetitions and an increase in weight/load
41
Does high load mean more pain?
there is a low correlation between pain and loading
42
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
43
How to improve pain with AT
improve self efficacy and education patients to build self-management skills is more important than specific educational approaches
44
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
45
Predisposing factors to insertional AT
genetics/hereditary pes cavus/high arches tight achilles tendon lateral WB through heel BMI improper/tight shoes over-training
46
surgery for insertional AT
considered only after > 6 months of active treatment without recovery
47
What is not recommended for IAT?
night splints steroid injections PRP
48
Achilles Tendon Rupture
most common complete tear peak at 3 to 5th decade 10% reported s/s before rupture >70% have tendinosis prior
49
Increasing incidence of AT rupture due to
sport participation later in life metabolic disease
50
MOI of ATR
usually during traumatic sporting event rapid df during forceful pf, eccentric overload
51
Patient history of ATR
reports pop, sniper shot from behind immediately disabling
52
RF for ATR
metabolic diseases immunosuppressive therapy neurovascular disease training
53
Exam of Achilles Rupture
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 5. + thompson test
54
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
55
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
56
Indications for non-operative ATR
rupture diagnosed and immob <72hr mid portion tear <10 mm patient goals post injury
57
Progressive early mob protocol, ATR
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
2-4 weeks Progressive early mob protocol
ARROM starting with isometrics to light band
59
4-5 wks Progressive early mob protocol
increase tband resistance and add seated heel raises
60
6 weeks Progressive early mob protocol
wean out of boot, gait and balance training
61
6-8 weeks Progressive early mob protocol
introduce standing heel raises with asymmetrical WB to symmetric
62
12 weeks Progressive early mob protocol
expect that 50% of pts can perform a unilateral heel raise
63
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
64
Things that prevent ATR RTS
Fear of reinjury Weakness inability as professional
65
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
66
AT changes after rupture repair
tendon gap visible up to 12 wks thicker tendon (10 mm) high vascularity tendon calcifications adhesions
67
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
68
Markers for ATR progress
seated SL heel raise at 50% BW gait pattern Standing SL heel raise at 100% BW decreased fear, increased confidence
69
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
70
High ankle sprain involves
AITFL, PITFL, interossesous membrane, malleolar fracture, proximal fibular spiral fracture
71
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
72
Exam of high ankle sprain
palpation of AITFL and PITFL, medial/lateral malleoli, all along fibula df lunge test
73
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
74
What grade of ankle sprain is the hardest to help?
grade 2, whether stable or unstable
75
Sprain without diastasis tx
WBAT
76
Sprain with diastasis tx
NWB in boot for 4-6 weeks
77
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
78
Low ligaments of ankle
post talofibular ligament anterior talofibular ligament calcaneofibular ligament
79
High ligaments of ankle
posterior tibiofibular ligament anterior tibiofibular ligament
80
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
81
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
82
Complications of acute lateral ankle sprain
avulsion fx of distal fibula bone bruising higher likelihood of OA fibularis tendinopathy chronic instability ROM deficits
83
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)
84
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
85
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
86
Chronic Ankle Instability
Recurrent episodes of ankle sprains and/or continud functional limitations for >1 yr
87
Possible mechanisms for CAI
excessive soft tissue laxity peroneal nerve injury decreased INV/EVE impaired proprioception
88
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
89
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
90
Reverse anterolateral drawer test
may be superior test because patients relax more and maintenance of proper translation plane is easier
91
Talar Tilt stress test
tests the CF ligament moving into inversion to assess for pain and end feel
92
Eversion Talar Stress TEst
testing the deltoid ligament done in inversion, comparing movement and pain

6 Orthopedics (17 decks)

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