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Applied podiatry. 301 > Lateral ankle, syndemosis and deltoid > Flashcards

Lateral ankle, syndemosis and deltoid Flashcards

1
Q

Name lateral ankle ligaments?

A

ATFL–>anterior talofibular ligament
CFL–> calcaneofibular ligament
PTFL—>Posterior talofibular ligament

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2
Q

in comparison of ATFL and CFL which one has a greater effect on inversion of ankle at DF?

A

CFL has a greater effect at DF. when CFL is cut at Df inversion of ankle joint increases significantly

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3
Q

among lateral ankle ligament which one is most commonly injured?

A

ATFL and least commonly is PTFL.

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4
Q

Describe mechanism of lateral ankle sprain injury?

A

Incident or landing of trauma resulting in ankle INV/PF

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5
Q

Based on the severity of the lateral ankle sprain explain the sequence of events that may happen?

A

1-Pt can identify a painful palpatory spot, can WB, minimal edema-likely no ligament rupture
2-Large edema, ecchymosis-high chance of ligament rupture
3- 4 days post surgery Ottawa ankle rules to exclude fracture

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6
Q

Ottawa ankle rules for x rays

A
  • Pain or bone tenderness in the posterior distal tibia or tip of medial malleolus
  • pain or bone tenderness in the posterior distal fibula or tip of latera l malleolus
    unable weight bear after the injury or for 4 steps in the emergency
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7
Q

mention two clinical tips for the investigation of a lateral ankle sprain?

A

palpate for pain or bone tenderness at the base of the 5th met
palpate medial malleolus or deltoid ligament region as 40% of athletes with lateral ankle ligament rupture present with medial ankle pain

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8
Q

in conjunction with the history of ankle sprain sequence, what are two physical examinations?

A

Anterior drawer test for ATFL instability
Talar tilt test for CFL instability

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9
Q

Describe the anterior drawer test

A
  • Leg on the edge of table in slight knee flexion to relax the gastro
    -Plantar flex ankle 5-10 degrees
    -Stabilise Tibia using one hand
    -Heel is gripped with the other hand
  • Translate heel anteriorly
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10
Q

Describe the anterolateral drawer test?

A

Stabilize the lower limb as in the anterior drawer
The thumb of translating hand is placed over the sinus tarsi with the tip touching the anterolateral surface of the lateral malleolus
as anterior translation is applied to the heel, talar movement and the associate sulcus can be assessed

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11
Q

Describe talar tilt test?

A

Ankle in a neutral position z
Distal tibia and fibular are stabilized
while the opposite hand provides a medial rotational force to stress the lateral portion of the joint
The mobilizing hand grasps the calc, but care should be taken to move the talus with the calcaneus so as to isolate the talocrural joint from STJ

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12
Q

why does physical examination of LAS is prefered to be done 4 days after injury?

A

This is because manual stress tests are less reliable due to inhibiting swelling and pain.

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13
Q

name an exercise for determining LAS.

A

WB lounge test, reduced ROM is indicative of LAS

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14
Q

What are the two categories of lateral ankle sprain clinically and explain it?

A

Grade 1 and Grade 3.
Grade 1- Clinically minor swelling and palpatory tenderness, hardly any functional loss and no increased instability.
Grade 3- Complete tear of the ligament and joint capsule rupture is present combined with severe bruising, swelling, and pain. There is a significant loss of function and an inc instability. The pt is unable to bear weight and walk normal

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15
Q

What imaging modality is preferred for coalition and bony avulsion?

A

CT scan

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16
Q

Name chronic ankle instability sequela?

A
  • Osteochondral lesion
  • Anterior impingement
    -Ankle arthritis
    -Peroneal tendon
    -Posteromedial impingement
  • Deltoid ligament injury
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17
Q

Describe the sequel of history/subjective of chronic ankle instability?

A

-Repeated episodes of lateral ankle sprain in a variety of settings
-Pt reported mechanical and psychological weakness
-Presence of pain along the anterior ankle joint with swelling post activity

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18
Q

mention physical examination for determination of chronic ankle instability?

A

Anterolateral/medial ankle joint tenderness
Reduce ROM in weight-bearing lunge test
Positive anterior drawer test, Talar tilt test
assessment of midtarsal ligament is critical -dorsal CCJ, bifurcate ligament, dorsal TNJ, and spring ligament
biomechanical assessment of cavo varus foot findings, NWB inv bias, rigid plantarflexed 1st ray, forefoot valgus
Reduce reach in star excursion test

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19
Q

What test is used to differentiate varus/ valgus position derived from rear foot or forefoot?

A

Coleman block test

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20
Q

Explain forefoot-driven varus?

A

-Forefoot rigid and hindfoot mobile
-Hindfoot varus moves to valgus

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21
Q

Explain hindfoot-driven varus.

A

Forefoot mobile, hindfoot rigid
Hindfoot remains in varus

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22
Q

What is anterior ankle impingemnt and Hx?

A

Anterior ankle pain in DF demanding activities with reduced mobility
History of recurrent ankle sprain
Presence of pain along the anterior ankle joint with swelling post activity

23
Q

What physical examination is performed for diagnosing AAI?

A

-Anterolateral/anteromedial ankle joint tenderness
-Reduced ROM in weight bearing-lunge test
-Pain in single or double leg squat
Positive dorsal impingement sign

24
Q

describe the positive dorsal impingement sign.

A

1-Dorsiflexion of the ankle with thumb pressure over the anterolateral aspect
2-Dorsiflexion of the ankle with no thumb pressure over the anterolateral aspect
3- The combined Manoeuvre which makes up the impingement sign

25
Q

Which view is ideal for bony spuring of ankle?

A

Lateral view

26
Q

Explain posterior ankle impingement and associated history?

A

-Persistent, isolated posteromedial ankle pain related to activity and dating back to an inversion injury
-intial lateral ankle symptoms following inversion injury
-insidious onset of posterio medial and medial activity related pain. typically after 4 to 6 weeks but can be longer

27
Q

Name posteromedial ankle impingement physical examination?

A

-Palpable tenderness behind the medial malleolus, deep to tib post tendon
-Pain with passive posteromedial digital pressure with ankle plantarflexion/inversion
No pain during palpation with resisted activated tib post tendon which differentiates the diagnosis form tib post tendinopathy
Nil symptoms of TP, FHL or FDL

28
Q

What imaging modality is best for the diagnosis of posteromedial ankle impingement?

A

MRI

29
Q

Describe the functionality of the syndesmosis joint?

A

-Provide a strong lateral buttress for the ankle mortise joint and resists the axial, rotational, and translational forces that attempt to separate the tibia and fibula

30
Q

What ligaments are involved in ankle syndesmosis?

A

AITFL, PITFL, IOL, and transverse ligament

31
Q

explain the biomechanic mechanism of ankle syndesmosis injury?

A

The foot is fixed in a position of external rotation and ankle df while a lateral force at the trunk or hip causes an internal rotation of the lower limb

32
Q

Describe biomechanic of syndesmosis injury in more details?

A

1-External rotation with the ankle in df and the foot pronated
2-This leads to external rotation of the fibula relative to the tibia, forcing the syndesmosis to open anteriorly, which is hinging on the PITFL
This mechanism leads to the AITFL becoming the first ligament injured
Further force and external rotation will lead to damage to the IOL and PITDL and deltoid

33
Q

explain the subjective clinical assessment of syndesmosis injury

A

-External rotation trauma with pain at the syndesmosis that may extend proximally
-inability to bear weight and swelling
-Pain with active and passive external rotation or Df of the foot and ankle.
Note: syndesmosis stress test is not sensitive or specific , so diagnosis should not be made on history and physical exam alone.

34
Q

mention some of the physical examination of suspected syndesmosis injury?

A

-Pain with passive external rotation /dorsiflexion
-Reproduction of pain in any positive point test, squeeze test, external rotation test, dorsiflexion test , Heel thump test
Early heel raise gait pattern to avoid Df range as well as push off pain

35
Q

Explain squeeze test

A

cup both hands around the distal tibia and fibula and exert compression to the syndesmosis

36
Q

Explain external rotation stress test

A

-Examiner stabilizes the leg with one hand and applies and external rotation load to the foot with the ankle in neutral

37
Q

Explain Dorsiflexion test for clinical assessment of syndesmosis injury?

A

Stabilise the leg with one hand and with the other hand applies a gentle but firm thumb on the heel with the fist. The force is applied on the centre of the heel and in line with the long axis of Tibia

38
Q

Name superficial and deep fibre of deltoid ligamnet?

A

Deep fibre–> Anterior tibiotalar ligament and posterior tibiotalar ligament
Superficial fibre–> Tibi calcaneal ligament, Tibi spring ligament and Tibionavicuar ligament
Calcaneonavicular ligament

39
Q

describe the deltoid-spring ligament complex?

A

The tibiospring ligament (TSL) has a broad connection to the superomedial part of the spring ligament(SMCNL). SMCNL builds up a sling around the talar head
Superficial deltoid forms a functional unit with the spring ligament complex to support and stabilise the talar head

40
Q

What is the functional role of the deltoid spring ligament?

A

The spring ligament forms a sling with the deltoid ligament around the talar head, thus providing stability to the talus against PF and adduction
Spring ligamen+deltoid support talocalcaneonavicular joint pronation and plantar arch maintenance
Note: the spring ligament is the primary restraint of the talus pf AND ADDUCTION WITH THE tIBIALIS POSTERIOR FUNCTIONING AS A SECONDARY DYNAMIC SUPPORT.

41
Q

What are the 3 injury mechanism of deltoid ligament or acute medial ankle instability?

A

1-Crush damage secondary to repeated LAS
2-High intensity movement
3-Direct eversion trauma where the foot cannot escape

42
Q

Chronic Medial ankle subjective presentation?

A

pt reports a giving way feeling especially towards the medial when on uneven ground, downhill or downstairs
Pt reports pain around the anteromedial ankle and sometimes pain in the lateral ankle particularly during loaded DF

43
Q

outline physical examination assessment of medial ankle instability?

A

NWB pain with palpation along the anteromedial gutter
laxity present during the valgus tilt stress test of the calcaneus
positive anterior drawer with slight plantarflexion and abduction stress
WB asymmetrical planus or hindfoot valgus
Correction of hindfoot valgus/pronation during DL squat
Note: gradual inc in hindfoot valgus/pronation during Dl squat activation of FHL creating forefoot supinatus during wb supination

44
Q

explain hindfoot correction in DL squat?

A
  • if a hindfoot corrects itself then a primary Tp dysfunction is excluded
    if partially corrected hindfoot valgus can be due to a tip post dysfunction or deep deltoid incompetence
45
Q
A
46
Q

Navicular drift and drop

A

IDK

47
Q

Supination resistance test

A

Pt is asked to stand in a relaxed position on two feet
relax their feet during the test and not help in any way
the clinician places the tips of the index and middle fingers just beneath the navicular
the clinician pulls directly upwards parallel to the tibia
the clinician notes the magnitude of the force that is required to supinate the foot from its resting position (1-5)

48
Q

what is Lateral medial ankle management none rehab technique?

A

POLICE–>
Protect
optimally
load
Ice
compress
elevate

49
Q

What is initial management of lateral/medial ankle instability?

A

1- Boot/brace such as Aircastwalker, ASO
2-Orthotic, tape, and brace (ankle taping, custom device). Orthotic addressing AJ/STJ instability

50
Q

The orthotic design concept for lateral foot instability?

A

-Stabilise STJ and ankle joint laterally.
-Prevent increased lateral deviation of STJ axis
-Create pronation moment at CCJ

51
Q

Name some of the orthotic design for lateral instability?

A

1-Lateral forefoot wedge, Morarty pad
2-High lateral heel cup, plantar EVA lateral arch fill
3- Cuboid notch
4-Lateral skive cast corrected to x everted degrees

52
Q

How does orthotics prevent or improve medial instability?

A

1-stabilize STJ
2-Prevent inc medial deviation of STJ axis
3- Reduce PF/ADD moment of talus/navicular

53
Q

name different orthotics designed for medial instability?

A

A 1-high medial heel cup or media flange
2-Medial EVA filler
3-forefoot varus wedge
4-medial heel skive

Applied podiatry. 301 (4 decks)

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