Lecture 5 - The Leg and foot Flashcards
What is medial tibial stress syndrome?
Periostitis (inflammation of the periosteum) of the tibia
What would the pain presentation be in medial tibial stress syndrome?
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
What are the common causes for medial tibial stress syndrome
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
What imaging is appropriate for medial tibial stress syndrome?
MRI
What would you expect to find in an objective assessment for medial tibial stress syndrome?
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
How would you treat medial tibial stress syndrome?
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
What is the pathophysiology behind a stress fracture?
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
What are the most common areas for stress fractures?
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
In what locations is a stress fracture at high risk of progressing to a full fracture?
Anterior tibia
Navicular
Medial malleolus
5th metatarsal
Sesamoids
What is the usual pain presentation with a stress fracture?
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
What is the gold standard imaging for stress fractures?
MRI, they are not usually picked up on x-rays
What is an extra thing to screen for with someone with a stress fracture and what is another marker of this
Problems with bone health i.e. osteoporosis, vitamin D and calcium deficiencies
Abnormal or absent menstruation is another marker in women
What is the assessment for a stress fracture?
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
How would you treat a stress fracture
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
What is the most common type of ankle sprain and what ligaments are injured
Inversion injuries
Talofibular ligament
Calcaneofibular ligament
Calcaneocuboid ligament
What is a high ankle sprain and what ligaments might be injured
Injury to the distal tibia/fibular syndesmosis
Anterior and posterior tibiofibular ligaments
Interosseous ligament
Inferior transverse ligament
What movements typically cause a high ankle sprain?
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
What type of ankle sprain will always cause an effusion
High ankle sprain
What symptoms are often missed after an ankle sprain and what can this cause?
Effusion and osteochondral damage
Can cause degenerative articular damage which can lead to people having to give up their sports
What is osteochondral damage?
Tear or fracture of cartilage and underlying bone in a joint (in the ankle this happens in the talus)
Why do ankle injuries have a high rate of reoccurence?
Damage to the proprioception receptors is common
Muscle atrophy affects proprioception and ability of the ankle to develop force
What position might someone with an ankle sprain hold their foot in?
Plantarflexion due to the swelling
How should passive dorsiflexion feel and what could differences indicate?
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
What passive movement tests can you do for the ligaments in the ankle?
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
What can potentially obscure the results of testing for pain in the calcaneofibular ligament by performing dorsiflexion and inversion?
Excessive subtalar movement
Avoid this by holding the talus and calcaneus as one while performing the test
How do you do the laxity test for the ankle?
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
How do you perform the squeeze test and why?
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
What additional test (on top of the squeeze test) can you do for an ankle sprain
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
How do you do an effusion test for intra-articular swelling
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
What is the punch test for?
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
What is a traumatic arthropathy?
Traumatic degenerative changes to the ankle joint which usually resolve by themselves
How should you treat an acute ankle sprain in the early stage?
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
How should an ankle sprain be treated if there is intra-articular damage
NWB and gentle progressive rehab
What exercises should be performed in longer term rehab of the ankle?
Proprioceptive exercises
Strengthening of the muscles around the ankle - progressed with weight bearing and impact exercises
What can braces be used for
Sensory feedback to prevent certain harmful movements
Preventing overpronation
What is plantar fasciitis?
Inflammation of the plantar fascia
What is the plantar fascia and what does it do?
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
What causes plantar fasciitis?
Repetitive, excessive, unaccustomed or prolonged stress
Aggravated by walking up hills or wearing worn or unsupportive footwear
If calves are tight why can this irritate the plantar fascia?
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
What symptoms would you expect in someone with plantar fasciitis?
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
What are some internal and external risk factors for plantar fasciitis?
Internal
Tight calves
Hyperpronation
Pes planus
External
Obesity
Standing jobs
High impact sports
What is the windlass test?
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
What can you palpate when suspecting plantar fasciitis and where is the tenderness most common?
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
What treatment can you provide for plantar fasciitis?
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
What joints can you mobilise in the foot and what can information can this give you?
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
