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athletic injuries 2036 > Lecture 12: foot and ankle injuries 2.0 > Flashcards

Lecture 12: foot and ankle injuries 2.0 Flashcards

1
Q

Subungual hematoma

A
  • bleeding underneath toenail
    (causes pressure and pain)
  • common in distance running and squash secondary to deceleration
    (toe hits end of toe box and causes disruption in nail/toe bed
  • also can be acute
    (drop a weight on it, get stepped on etc)
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2
Q

treatment of acute subungual hematoma

A
  • need to evacute blood to decrease pressure
  • can be done with a sterile heated paper clip
  • use pliers to hold clip
  • press into nail. blood will release
  • manual pressure on nail to evacuate all blood-band-aid
    -may have to do a few days to get it all. only need clean paperclip next day - no need to heat
  • new nail will grow underneath and push the old nail off
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3
Q

prevention of subungal hematoma

why would you do? why?
a) pad end of shoes
b) get bigger shoes
c) cut toe nails shorter
d) pad forefoot

A

d) pad forefoot

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4
Q

ingrown toenail

A
  • more common in males than females
  • large toe is most often affected
  • inflamed skin grows over the lateral nail fold
  • moderate to severe lesions may have foul smelling discharge and ongoing symptoms
  • usually results from lateral pressure of poorly fitting shoes, improper trimming, or repeated trauma
  • severe cases are treated surgically
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5
Q

conservation treatment/prevention for ingrown toenails

A

proper trimming
1: trim weekly by cutting straight across
2: avoid rounding so that margins do not penetrate the tissues on the side
3: should be left long enough to clear underlying skin, but not to much that it pushes into sock

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6
Q

conservative treatment for mild to moderate cases of ingrown toenails

A

1: soak in warm water. to make tissue is soft and palpable
2: then “tease” tissue back, away from nail with manicure stick
3: take a strand of cotton ball, wet it and roll until cylindrical
4: tuck cotton along border of nail, bllot out excessive moister and trim
5: may need to be done 2x/day until inflammation settles
6: allow nail to grow just beyond toe cut small v shape in nail
- this provides stress releif point in nial

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7
Q

ankle functional anatomy: stability comes from”

A

1: shape of bones
2: passive stabilizers (capsules and ligament)
3: dynamic stabilizers (muscles that cross the joint)

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8
Q

the bones of the ankle

A
  • ankle joint AKA talocrural joint
  • the ankle mortice is a u-shaped structure making up the top of the talocrural joint
  • made up of:
    • lower end of tibia
    • medial malleolus (Tibia)
    • Lateral malleolus (Fibula)
  • lateral malleolus longer and more posterior than medial
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9
Q

bones of the ankle: the talus

A
  • has no muscles that attach to it
  • very extensive articular surface
  • convex on top and concave on the sides
    • allows it to better articulate with t he tibia and fibula
  • trochlear surface (top) is wider anteriorly than posteriorly
  • with dorsiflexion the wider portion lies between the malleoli (tibia and fibula)
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10
Q

bones of the ankle - the fibula

A
  • with dorsiflexion
  • fibula externally rotates and it moves superiorly
  • external rotation of fibula increases the tension in the structures that hold the tibia and fibula together
  • opposite happens in plantar flexion
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11
Q

Ottawa ankle rules: lateral malleolus

A
  • an ankle x-ray is only required if there is any pain in the malleolar zone and
    1: bone tenderness at the posterior edge or tip of the lateral malleolus (A)

or

2: bone tenderness at the posterior edge or tip of the medial malleolus (B)

or

an inability to bear weight both immediately and in the emergency department for four steps

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12
Q

ottawa ankle rules - for midfoot

A

a foot x-ray series is only required if there is any pain to the midfoot zone and
1: bone tenderness at the base of the 5th metatarsal (C)

or

2: bone tenderness at the navicular (D)

or

3: inability to bear weight both immediately and in the emergency department for four steps

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13
Q

passive stabilizers - capsule and ligaments of the ankle

A
  • ankle is surrounded by fibrous capsule
    • thin and weak anteriorly and posteriorly to allow movement
  • talocrucal joint is further strengthened medially and laterally by ligaments
    • some communicate (ATF, PTFL ) with the capsule while others do not
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14
Q

when does the capsule in the ankle swell?

A

when there are injuries to ATFL or PTFL

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15
Q

passive stabilizers - anterior talofibular ligament

A
  • communicated with/is within capsule
    • increased swelling?
  • begins on the lateral malleolus and travels anteriorly to the talus at the 90 degree angle
    • 2 bundles (superior and inferior)
  • considered the weakest of the lateral ligaments
  • increased strain in plantar flexion as the talus glides forward out the mortise
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16
Q

passive stabilizers - special test

A
  • used to determine damage to anterior talofibular ligament primarily
  • tested in slight plantar flexion
  • a positive test occurs when foot slides forward and/or makes a slunking sound as it reaches the end point
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17
Q

passive stabilizers - calcaneofibular ligament

A
  • extra capsular ligament
  • in the neutral ankle position, it originates on anterior part of the lateral malleolus, below the ATFL and runs downward and backwards to attach to the posterior/ lateral calcaneal surface
  • provides stability to the lateral talcrucal joint as it moves into dorsiflexion, but it does not directly stabilize this joint. subtalar joint stabilizer
  • up to 3.5 x’s stronger than the ATFL
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18
Q

passive stabilizers - posterior talofibular ligament

A
  • communicates with/is within capsule
    • increase swelling?
  • begins on the lateral malleolus and travels posteriorly around the talus at a180 degree angle to the ATFL
    • extends to most medial part of posterior talus
  • primarily supports talocrural joint in dorsiflexion
    • may provide secondary support to talocrural joint throughout range
  • has some fibers that communicate with the ATFL
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19
Q

passive stabilizers - deltoid ligament

A
  • deltoid ligament - limits talar/subtalar abduction or lateral tilt
  • very broad from front to back
  • described as up to 6 bands with considerable variability anatomically
    • anterior part is tight in plantar flexion
    • middle portion in neutral
      -posterior portion tight in dorsiflexion
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20
Q

passive stabilizers - special tests

A
  • performed to determine extent of injury to the calcaneofibular ligament (inversion) or deltiod ligament (eversion)
  • with foot at 90 degrees, the calcaneus is inverted. pain and excessive motion indicates injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments
  • if the calcaneus is everted, the deltoid ligament is tested
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21
Q

dynamic stabilizers (muscles)

A
  • muscles crossing the ankle joint contribute to its stiffness and may be protective
  • peroneus (fibularis) longus and brevis may contract concentrically or eccentrically to provide dynamic support to slow down or stop movement into a dangerous range
  • controls rear foot supination
  • muscles on the anterior aspect may also contract to slow the plantar flexion component of supination and protect the lateral ligaments
  • muscles of the medial aspect of the ankle may help prevent eversion sprains in the same way
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22
Q

ankle sprains: the numbers

A
  • most common injury in sports
  • 37/1000 persons per year in general population
    23% of all sport injuries
  • number vary literature but we see roughly 85% lateral, 10% syndesmosis, 5% medial
  • responsible of 1/4 of lost time in basketball and football
23
Q

what are the properties of the ligaments

A
  • wave or crimp across ligament
  • built into the structure of the ligament
  • injury can be closely correlated to the load-deformation curve
  • 3 phase of curve
    • toe region
    • linear region
    • rupture region
24
Q

toe region and early linear region

A

1: initial concave region

2: represents normal physiological range of strain = o-2% of length

3: early linear region 2-4% due to flattening of crimp

4: repeated cycling of stretch in this range is reversible

25
Q

ligament strains

A
  • pathological irreversible ligament elongation occurs
  • as this continues intra and inter-molcular cross-links are disrupted until macroscopic failure is clinically evident

early part= mild/grade 1: <50%

2nd part = grade 2 : 50-80% fiber disruption, obvious clinical laxity

3rd part = grade 3: rupture zone 80-100%

26
Q

when do ankle sprains usually occur?

A
  • usually occur with loading and unloading
  • with closed kinetic chain plantar flexion, the talus is positioned anteriorly in the ankle mortise
  • the primary restrain for excessive anterior talar glide in the ATFL
  • while loaded, the ankle is more stable in mortise
27
Q

deltoid ligament sprain

A
  • least common sprain
  • eversion mechanism of injury
  • stability of the medial ankle depends upon the deltoid ligament and supported by lateral malleolus
28
Q

symptoms of a deltoid ligament sprain

A
  • eversion mechanism of injury
  • pain on the medial side of the ankle
  • may report instability with high grade sprain
29
Q

signs of a deltoid ligament sprain

A
  • pain with active and passive eversion
  • pain.laxity, endpoint? findings with talar tilt (eversion)
  • possible pain with resisted inversion (dynamic stabilizers)
  • may have increased pronation
    • navicular dropped?
  • pain on palpation over the deltoid ligament
30
Q

anterior talofibular ligament sprain

A
  • most common sprain
  • inversion in plantar flexion mechanism of injury
31
Q

symptoms of anterior talfibular ligament sprain

A
  • inversion mechanism of injury
  • pain on the lateral side of the ankle, anterior to malleolus
  • may report instability with high grade sprain
32
Q

sings of anterior talobubular ligament sprain

A
  • pain with active and passive inversion in plantar flexion
  • pain, laxity, endpoint? findings with anterior draw test
  • possible pain with resisted eversion (dynamic stabilizers)
  • pain on palpation over the anterior talofiubular ligament
33
Q

calcaneofibular ligament sprain

A
  • 3.5x stronger than ATFL
  • inversion in dorsiflexion mechanism iof injury
34
Q

symptoms of clacaneofibular ligament sprain

A
  • inversion mechanism of injury in neutral to slight dorsiflexion
  • pain on the lateral side of the ankle below malleolus
  • may report instability with high grade sprain
35
Q

signs of calcaneofibular ligament sprain

A
  • pain with active and passive inversion in neutral
  • pain, laxity, endpoint? findings with talar tilt (inversion)
  • possible pain with resisted eversion (dynamic stabilizers)
  • pain on palpation over the CFL ligament
36
Q

what does an ankle sprain “look” and “sound “ like?

A
  • what was the MOI
    • inversion or eversion
    • plantar-flexed or dorsiflexed
  • were you able to continue?
    • speaks to initial injury severity/level of function
  • unable to bear weight or gross instability - significant injury
  • need to make sure it isn’t fractured
  • did you hear or feel a pop or crack?
    • fracture/significant ligament injury
37
Q

if your able to walk not run means —

A

grade 2 injury

38
Q

if your able to run following

A

grade 1 injury

39
Q

helpful questions to see if you have an ankle injury

A
  • did it swell? how quickly
    • capsular vs non capsular
  • how bad is the pain
    • 7/10
      -positions that make it worse?
    • plantar and inversion
40
Q

objective-observation of ankle injures

A

what are we looking for?
- swelling
- obvious deformity
(lower leg, ankle, foot)
- weight bearing
(static … equal pressure front/back, side to side)
(dynamic… guarded/painful movement)

41
Q

special tests - contractile

A
  • which muscle are we concerned about?
    • preoneus longus
  • what movement do we want to test?
    • eversion, plantar flexion
  • how do we quantify?
    • oxford scale - move through full range against gravity
  • how we we interpret this?
    • 3/5 –> grade 2 strain
42
Q

special tests - non-contracile tissue

A
  • which one(s) apply?
    • do we need to do all the ankle tests we know
  • anterior drawer test
  • taylor tilt
  • external rotation
  • Ottawa ankle
43
Q

special tests- non-contractile tissue positive test

A
  • positive anterior drawer
  • significant anterior movement (grade 3 ATFL)
  • no end point
  • minimal pain
44
Q

special tests - non-contractile tissue negative tests

A
  • Ottawa ankle rules
  • external rotation
  • talar tilt
45
Q

diagnosis/clinical impression

A

peroneus longues strain (grade 2 3/5)

ATFL ligamanet sprain
- grade 3
- significant swelling
- laxity ++
- no end point

46
Q

ankle sprain prognostic indicators

A
  • higher age, poor weight bearing status and higher grade of injury at baseline are associated with poorer outcomes
  • not achieving full ROM within 2 weeks may be a sign of accompanying injury
  • medial pain on palpation (bone bruise) and pain with dorsiflexion at week 4 were prognostic of poorer function at 4 months
47
Q

ankle sprain treatment - inflammation/destruction

A
  • protect injured tissue (crutches) & palliate
  • optimal loading
    • maintain ROM in uninjured tissue
  • ice, compression, elevation as indicated
48
Q

ankle sprain treatment - repair

A
  • heat –> promote healing
  • begin ROM ex. and idealize by 2 weeks
  • maintain strength of uninjured tissue
  • begin gentle strengthening of injured tissue, once ROM is achieved
  • increase weight bearing
  • begin proprioception exercise to re-teach dynamic stabilizers to take a certain shape
49
Q

treatment for ankle sprains - late repair/ remodelling

A
  • idealize strength of dynamic stabilizers through range
  • continue with balance and coordination training
    • repetition in practice helps develop effective movement solutions
    • aids in avoidance of re-injury as the cognitive load decreases and we “tune” perception and action
  • this will allow for improved agility and power (jumping, cutting, push-off, etc
  • decide on return to play taping or bracing x 1 year
50
Q

what is the injury when the foot has pain on its first step in the morning

A

plantar fasciitis

51
Q

isometic contraction in neurtral position

A

resisted movement testing

52
Q

hawkins kennedy and neer’s

A

shoulder impingement

53
Q
A

athletic injuries 2036 (20 decks)

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