Lecture 5 - The Leg and foot

Question 1

What is medial tibial stress syndrome?

Answer 1

Periostitis (inflammation of the periosteum) of the tibia

Question 2

What would the pain presentation be in medial tibial stress syndrome?

Answer 2

Pain linearly (as oppose to focally) on medial distal 1/3 or 1/2 of tibia

Pain on loading through lower limb i.e. running and climbing

Eases with rest

Question 3

What are the common causes for medial tibial stress syndrome

Answer 3

Usually occurs due to a change i.e. change in training levels for an event, change in walking route that takes someone up more hills, change in footwear etc

Question 4

What imaging is appropriate for medial tibial stress syndrome?

Answer 4

MRI

Question 4

What would you expect to find in an objective assessment for medial tibial stress syndrome?

Answer 4

Palpation - feel along medial tibial border and look for tenderness

ROM and resisted movements - no pain

Tap along medial tibial border with tendon hammer and look for tenderness

Plantarflex and invert repeatedly - if severe this will cause pain as these movements repeated put strain on the periosteum

Get patient to hop - slapping sound of foot = weak plantarflexors

Question 5

How would you treat medial tibial stress syndrome?

Answer 5

Remove causative factors and rest
If athlete maintain fitness using non-WB activities such as cycling (as long as body isn’t sat over lower limb)
Stretching (dorsiflexors and everters) and strengthening (plantarflexors)
Activity modification and gradual return
Reduce inflammation - periosteum = superficial so NSAIDs, acupuncture and ice can all be effective

Question 6

What is the pathophysiology behind a stress fracture?

Answer 6

Repetitive/excessive stress on the bone occurs. This overloading accelerates initiation of the bone remodelling process which means that bone cells then get resorbed quicker than the body can replace them leaving people susceptible to micro fractures

Question 7

What are the most common areas for stress fractures?

Answer 7

The junction between the middle and proximal 3rds of the tibia anteriorly or posteromedially

Distal fibula

Navicular

2nd-3rd metatarsals

Base of 5th metatarsal

Sesamoids on big toe

Medial malleolus

Calcaneous

Question 8

In what locations is a stress fracture at high risk of progressing to a full fracture?

Answer 8

Anterior tibia

Navicular

Medial malleolus

5th metatarsal

Sesamoids

Question 9

What is the usual pain presentation with a stress fracture?

Answer 9

Focal pain (pointed to with two or three fingers)

Deep ache that initially eases with rest but progresses steadily to include night pain and resting pain

Therefore pain that gets worse with use and begins earlier and earlier into activity

Question 10

What is the gold standard imaging for stress fractures?

Answer 10

MRI, they are not usually picked up on x-rays

Question 11

What is an extra thing to screen for with someone with a stress fracture and what is another marker of this

Answer 11

Problems with bone health i.e. osteoporosis, vitamin D and calcium deficiencies

Abnormal or absent menstruation is another marker in women

Question 12

What is the assessment for a stress fracture?

Answer 12

Tap with a tendon hammer over common stress fracture areas and look for pain/tenderness

Single leg hopping may be painful

No single test of proven reliability

Question 13

How would you treat a stress fracture

Answer 13

Patient needs to rest, no loading activities and require crutches

Can use splinting, boots etc but these are just to remind the person of their need to rest and not because they will specifically help the fracture to heal better

Build exercise up gradually beginning with non weight bearing exercises

Surgery if doesn’t heal - more common in the high risk fractures

Question 14

What is the most common type of ankle sprain and what ligaments are injured

Answer 14

Inversion injuries
Talofibular ligament
Calcaneofibular ligament
Calcaneocuboid ligament

Question 15

What is a high ankle sprain and what ligaments might be injured

Answer 15

Injury to the distal tibia/fibular syndesmosis
Anterior and posterior tibiofibular ligaments
Interosseous ligament
Inferior transverse ligament

Question 16

What movements typically cause a high ankle sprain?

Answer 16

Forced dorsiflexion - the talus is wider at front and so forcible dorsiflexion causes the syndesmosis to be disrupted (forces tibia and fibula apart)

External rotation

Question 17

What type of ankle sprain will always cause an effusion

Answer 17

High ankle sprain

Question 18

What symptoms are often missed after an ankle sprain and what can this cause?

Answer 18

Effusion and osteochondral damage
Can cause degenerative articular damage which can lead to people having to give up their sports

Question 19

What is osteochondral damage?

Answer 19

Tear or fracture of cartilage and underlying bone in a joint (in the ankle this happens in the talus)

Question 20

Why do ankle injuries have a high rate of reoccurence?

Answer 20

Damage to the proprioception receptors is common
Muscle atrophy affects proprioception and ability of the ankle to develop force

Question 21

What position might someone with an ankle sprain hold their foot in?

Answer 21

Plantarflexion due to the swelling

Question 22

How should passive dorsiflexion feel and what could differences indicate?

Answer 22

Dorsiflexion with extended knee - should be springy end feel, if squishy an effusion is indicated and if hard indicates degenerative changes in talocrural joint

Dorsiflexion with flexed knee - end feel should be hard as it is now a bony stop rather than being stopped by the gastro-soleus complex

Question 23

What passive movement tests can you do for the ligaments in the ankle?

Answer 23

Plantarflexion and inversion - if pain then indicates ATFL

Dorsiflexion and inversion - if pain, laxity and a spongy end feel this indicates calcaneofibular ligament

Dorsiflexion and eversion - deltoid ligament indicated if pain

Question 24

What can potentially obscure the results of testing for pain in the calcaneofibular ligament by performing dorsiflexion and inversion?

Answer 24

Excessive subtalar movement
Avoid this by holding the talus and calcaneus as one while performing the test

Question 25

How do you do the laxity test for the ankle?

Answer 25

Hold the talus with thumb and fingers in the area where it joints to the tibia and fibula

Push the tibia and fibula with your other hand and feel for pain and movement

Increased movement or pain compared to the other side indicates a potential ATFL tear

Significant movement indicates ATFL and potentially a calcaneonavicular ligament injury

Question 26

How do you perform the squeeze test and why?

Answer 26

Squeeze test for high ankle sprains

Squeeze tibia and fibular together higher up, if there is pain across the tibiofibular mortice then this is positive for a high ankle sprain

Question 27

What additional test (on top of the squeeze test) can you do for an ankle sprain

Answer 27

Dorsiflexion and external rotation with leg flexed to 20 degrees, hold the tibiofibular mortice just proximal to the talus

If there is pain and increased movement (although sometimes you don’t get this far as it’s very uncomfortable for the patient) this indicates a high ankle sprain

Question 28

How do you do an effusion test for intra-articular swelling

Answer 28

Patient in prone
Feel swelling around the achilles and put fingers gently either side
Dorsiflex the foot bringing into a closed pack position therefore increasing the size and tension of the swelling and then plantarflex and the swelling should reduce under your fingers

Question 29

What is the punch test for?

Answer 29

Punch the base of the calcaneous
Increased pain on one side compared to the other is positive for potential intra-articular lesions and osteochondral defects

Question 30

What is a traumatic arthropathy?

Answer 30

Traumatic degenerative changes to the ankle joint which usually resolve by themselves

Question 31

How should you treat an acute ankle sprain in the early stage?

Answer 31

RICE - aim to reduce swelling and effusion and protect ligaments from further damage

Try to maintain movement in pain free range where possible to prevent joint stiffness

Question 32

How should an ankle sprain be treated if there is intra-articular damage

Answer 32

NWB and gentle progressive rehab

Question 33

What exercises should be performed in longer term rehab of the ankle?

Answer 33

Proprioceptive exercises
Strengthening of the muscles around the ankle - progressed with weight bearing and impact exercises

Question 34

What can braces be used for

Answer 34

Sensory feedback to prevent certain harmful movements
Preventing overpronation

Question 35

What is plantar fasciitis?

Answer 35

Inflammation of the plantar fascia

Question 36

What is the plantar fascia and what does it do?

Answer 36

Attaches to the heel bone and the balls of the toes/foot
It acts like a bowstring to support the arch of the foot and provides shock absorption and tension

Question 37

What causes plantar fasciitis?

Answer 37

Repetitive, excessive, unaccustomed or prolonged stress

Aggravated by walking up hills or wearing worn or unsupportive footwear

Question 38

If calves are tight why can this irritate the plantar fascia?

Answer 38

The ankle tries to achieve dorsiflexion in other ways if the calf is tight which can include at the subtalar joint, this then includes a pronation force also which creates a torsion effect on the plantar fascia

Question 39

What symptoms would you expect in someone with plantar fasciitis?

Answer 39

Pain under the heel while walking, standing or rising
As it worsens pain on getting up
Can have restricted calf, ankle or mid-tarsal joints

Question 40

What are some internal and external risk factors for plantar fasciitis?

Answer 40

Internal
Tight calves
Hyperpronation
Pes planus

External
Obesity
Standing jobs
High impact sports

Question 41

What is the windlass test?

Answer 41

Patient is in prone lying with their knee bent to 90 degrees and the big toe is put into extension

This should make the plantar fascia more visible, if it’s not visible it’s likely not intact which is a big problem

Question 42

What can you palpate when suspecting plantar fasciitis and where is the tenderness most common?

Answer 42

Palpate along the plantar fascia and have the patient inform you of any pain or tenderness

Tenderness tends to be at medial tubercle of calcaneus

Question 43

What treatment can you provide for plantar fasciitis?

Answer 43

NSAIDs and ice - superficial so ice is useful

Remove/adjust causative factor

If tight gastrocs is an issue then soft tissue work and stretching of the gastroc could be appropriate although be careful not to further irritate the fascia

Mobilise - mid-tarsals and sub-talar joint

Strapping, heel pads and orthotics - this should be used very judiciously and temporarily as when removed the plantar fascia is shortened which creates lots of problems

Injections/dry needling/shockwave - alternative pain managements, to be used as a last resort

Question 44

What joints can you mobilise in the foot and what can information can this give you?

Answer 44

Talocrural joint - if a hard end feel during dorsiflexion it indicates degenerative changes in the joint

Subtalar joint - prone position, knee to 90 and feel the talus at the tibiofibular mortise and perform inversion and inversion with the web of your hand round the head of the talus allowing you to examine the subtalar joint, decreased movement or pain can be caused by ligament strains that caused articular damage

Mid-tarsals - Pull the calcaneus caudad, invert, evert, plantarflex and dorsiflex the foot, reduced movement and pain could implicate degenerative changes in these joints