Leg and ankle

Question 1

Named the anterior compartment of the leg:

Answer 1

• Tibialis anterior
• Ext. Hallicus longus
• Extensor digitorum longus
• Peroneus tertius

Question 2

What is the artery and nerve supply of the anterior compartment:

Answer 2

ant. tibial artery and deep peroneal nerve.

Question 3

Describe function, mechanics, anatomy of the ant. compartment of the leg:

Answer 3

• Also called the pretibial mm.
• proximal attachements on the anterior and lateral aspects of the proximal half of the tibia, the adjacent fibula and the interosseous membranes.
• tendons crossed the dorsal part of the ankle restrained by synovial lined superior and inferior retinaculum.
• they are all dorsiflexors because they cross anterior to the axis of rotation at the talocrural joint.
• those mm are most active during the first stance of walking and during the swing phase of gait.
• during early stance , they act eccentrically to control the plantar flexion (period between the heel contact and foot flat) in order to generate a soft landing of the foot.
• During swing phase, the dorsiflexor ensures the propulsion at the ankle joint and the toes for the foot to clear the ground.
  Notes: know the actions of the muscles, eversion and abduction influence the extensor digitorum longs and fibulas tertius must counter balance the inversion and adduction of the tibias anterior.

Question 4

Actions, innervations of tibias anterior:

Answer 4

• in addition to dorsiflexion, TA does inversion and adduction at the talonavicular joint as well as providing secondary support to the medial longitudinal arch.
• innervated by the deep branch of the fibular nerve (originated to the common fibular nerve L4-S2)

Question 5

Actions, innervations of extensor hallucis longus:

Answer 5

• dorsiflexion at the talocrural joint and extension of the great toe.
• innervated by the deep branch of the fibular nerve (originated to the common fibular nerve L4-S2)

Question 6

Actions, innervations of extensor digitorum longs and fibularis tertius:

Answer 6

• dorsiflexion
• eversion of the foot.
• • innervated by the deep branch of the fibular nerve (originated to the common fibular nerve L4-S2)
    note: fibularis tertius is part of the extensor digitorum longs muscle and may be considered as this muscle’s fifth tendon because it attaches to the base of the fifth metatarsal bone.

Question 7

Named the muscles of the lateral compartment of the leg:

Answer 7

• fibularis longus and brevis. (or Peroneus longus or brevis)

Question 8

What is the artery and nerve supply of the lateral compartment:

Answer 8

• superficial branch of the fibular nerve, L4-S1 - fibular artery

Question 9

Describe anatomy of the lat. compartment of the leg:

Answer 9

• The FIBULARIS LONGUS is the larger and more superficial muscle within the compartment.

Attachments
The fibularis longus originates from the superior and lateral surface of the fibula and the lateral tibial condyle.
The fibres converge into a tendon, which descends into the foot, posterior to the lateral malleolus.
The tendon crosses under the foot, and attaches to the bones on the medial side, namely the medial cuneiform and base of metatarsal I.

Actions: Eversion and plantarflexion of the foot. Also supports the lateral and transverse arches of the foot

• The FIBULARIS BREVIS muscles is deeper and shorter than the fibularis longus.
  Attachments:
  Originates from the inferolateral surface of the fibular shaft. The muscle belly forms a tendon, which descends with the fibularis longus into the foot.
  It travels posteriorly to the lateral malleolus, passing over the calcaneus and the cuboidal bones.
  The tendon then attaches to a tubercle on metatarsal V.
  Actions: Eversion of the foot.

Question 10

Explain the biomechanics of the lateral compartment:

Answer 10

• fibularis longus and TA attach on either side of the plantar surface first tarsometatarsal joint. This pair together to provides kinetic stability to the base of the first ray.
• tendon of the mm passes posterior to the lateral malleolus and occupy the synovial sheath under the fibular retinaculum.
• are the primary evertors.
• provide main source of stability to the lateral side of the ankle.
• very effective at resisting inversion in slow movement, a purely reflexive muscular contraction in response to unexpected inversion movement is typically too slow to prevent injury.
• have substantial moment arms for eversion across the subtalar joint over 2 cm. The lateral malleolus serve as a fixed pulley, routes the fibular tendons post. to the axis of rotation at the talocrural joint. Therefore they also serve as plantar flexors of the talocrural joint.
• fibularis longus stabilises the first tarsometatarsal joint against the potent medial pull of the tibialis anterior. without this stability, the first ray may migrate medially, predisposing a person to a hallux valgus deformity.
• Most active during middle and late stance phases of walking, where the foot is inverting, they also serves as decelerating, and control the rate and extend the subtalar joint.
• assist other mm for plantar flexion.

Question 11

Named the mm of the posterior superficial group:

Answer 11

• plantar flexors
• gastrocnemius
• Soleus
• Plantaris

Question 12

Named the mm of the deep superficial group:

Answer 12

• Tibialis posterior, flexor digitorum longus, flexor hallucis longus.

Question 13

What is the innervation of the mm and blood supply of the posterior compartment:

Answer 13

• tibial nerve L4-S3

- post. tibia artery

Question 14

Explain the biomechanics of the posterior compartment:

Answer 14

All mm that plantar flexes the talocrural joint also supinate (invert) the subtler or transverse tarsal joints.
Forces of the achilles tendons passes just medial to the subtalar joint axis of rotation.
Tibialis post, flexor hallucis longus and flexor digitorum longus are the primary investors.
- plantaris often remains intact when achilles ruptures, acts with the Gastroc to plantar flex and contains high density muscles spindles, proprioceptive functions for more powerful action.
- mm switch to concentric activation to assist necessary thrust for push off and early swing phase during walking (btw heel off and toe off the ground)
- mm act eccentrically when foot on the ground to decelerate the dorsiflexion.

Question 15

Named the nerve supply of the leg, ankle and foot:

Answer 15

Deep peroneal nerve: tibialis anterior (L4, L5), extensor hallucis longus (L5) and extensor digitorum longus (L5)

Superficial peroneal nerve: peroneus longus and brevis (L5, S1)

tibial nerve: gastrocnemius (S1, S2), soleus (S1, S2), flexor hallucis longus (L5), flexor digitorum longus (L5) and tibialis posterior (L5).

Question 16

Named the blood supply to the leg.

Answer 16

Origin from the aorta, iliac artery, femoral artery and anterior tibia artery.

Question 17

Explain the difference between the type 1 and type 2 fibres

Answer 17

It is generally accepted that muscle fiber types can be broken down into two main types: slow twitch (Type I) muscle fibers and fast twitch (Type II) muscle fibers. Fast twitch fibers can be further categorized into Type IIa and Type IIb fibers.

These distinctions seem to influence how muscles respond to training and physical activity, and each fiber type is unique in its ability to contract in a certain way. Human muscles contain a genetically determined mixture of both slow and fast finer types

Slow Twitch Muscle Fibers (Type I)
The slow muscles are more efficient at using oxygen to generate more fuel (known as ATP) for continuous, extended muscle contractions over a long time. They fire more slowly than fast twitch fibers and can go for a long time before they fatigue.

Therefore, slow twitch fibers are great at helping athletes run marathons and bicycle for hours.

Fast Twitch Muscle Fibers (Type II)
Because fast twitch fibers use anaerobic metabolism to create fuel, they are better at generating short bursts of strength or speed than slow muscles. However, they fatigue more quickly.

Fast twitch fibers generally produce the same amount of force per contraction as slow muscles, but they get their name because they are able to fire more rapidly. Having more fast twitch fibers can be an asset to a sprinter since she needs to quickly generate a lot of force.

Fast Twitch Muscle Fibers (Type IIa)
These fast twitch muscle fibers are also known as intermediate fast-twitch fibers. They can use both aerobic and anaerobic metabolism almost equally to create energy. In this way, they are a combination of Type I and Type II muscle fibers.

Fast Twitch Muscle Fibers (Type IIb)
These fast twitch fibers use anaerobic metabolism to create energy and are the “classic” fast twitch muscle fibers that excel at producing quick, powerful bursts of speed. This muscle fiber has the highest rate of contraction (rapid firing) of all the muscle fiber types, but it also has a faster rate of fatigue and can’t last as long before it needs rest.

Question 18

Give examples of type 1 fibres and type 2 fibres:

Answer 18

Type 1 Fibres:
Red, slow, slow oxidative, thinner, rich mitochondria, slow/postural tonic/postural mm. 
Soleus 
Popliteus 
Psoas 
Supraspinatus 
Posterior fibres of Deltoid 
Posterior fibres of Temporalis 

Type 2 Fibres:
White pink, white, intermediate A, fast B fast oxidative (A), fast glycolytic (B) medium A, thick B and low in mitochondria, moderate to fast/phasic muscles.
Ocular muscles 
Hand muscles 
Foot muscles 

Majority of hip and shoulder girdle muscles
Most Type 2 muscles are a mixture of type 2A & 2B
Erector spinae
Scalenes

Question 19

Explain the anatomy and biomechanics of the talocrural joint:

Answer 19

• upper ankle joint.
• maintain by connective tissues that bind the tibia with the fibula.
• provides major sources of natural stability. referred as carpenter’s mortise joint.
• it accepts the forces that pass between the leg and the foot. 90%-95% of the force pass through the talus and the fibula, the remaining 5% to 10% pass through the lateral side.
• lined with 3mm of articular cartilage, which can be compressed by 30%-40% in response to peak loads. This load absorption protects the subchondral bone from damaging stress.
• thin capsule surrounds the talocrural joint reinforced by collateral ligaments that helps with stabilisation between the talus and the mortise.
• Medial collateral ligament of the talocrural joint is called the deltoid ligament.

Question 20

What are the ligaments of the deltoid ligaments and the function:

Answer 20

• tibionavicular fibers
• tibiocalcaneal fibers.
• Tibiotalar fibers.
• limit eversion across the talocrural, subtler, and talonavicular joints. Sprains is very uncommon because of the ligament strength and the lateral malleolus serves as a bony block against excessive eversion.

Question 21

What are three major component of the lateral collateral ligaments of the ankle and the general function:

Answer 21

• Anterior talofibular ligament: most frequent injured by excessive inversion or adduction of the ankle.
• Calcaneofibular ligaments: resist inversion
• Posterior talofibular ligaments:stabilise the talus
• inability to block the medial side of the mortise, the overwhelming majority of ankle sprains involve excessive inversion, often involving injury to the lateral collateral ligaments.

Question 22

Explain the anatomy and the biomechanics of the subtler joints:

Answer 22

• lower ankle
• under talus
• consists of three articulations formed btw posterior, middle, and anterior facets of the calcaneus and the talus.
• use for complex kinematics involving leg and talus as a single unit rotating over the calcaneus. This mobility allows the foot to assume positions on stable motion for example: walking across a step hill, standing with feet held wide apart, quickly changing directions while walking or running, and keeping one’s balance on a rocking boat.
• open chain: inversion /eversion
• closed chain: supination/pronation

Question 23

What are the special test for assessing the leg, ankle and foot:

Answer 23

Leg: compression, thompson test, human tests.
Ankle:ligaments tests: anterior/posterior draw, lateral ligament stability, tinel’s sign.

Question 24

What are the causes of distal paraesthesia?

Answer 24

Vb12 deficiency.
heavy metal poisoning
HIV
systemic lupus erythematosus
malnutrition

Question 25

What are the red flags when assessing the leg:

Answer 25

• Fractures and dislocation. History of trauma, sports injury, osteoporosis, joint effusion, bruising swelling, unwilling to bear weight on involved leg.
• infection (septic arthritis), fever, constant ache, joint swelling, tenderness, warmth, surgery
• peripheral arterial occlusive disease, age >55, diabetes ischemic heart disease, smoking, sedentary lifestyle, intermittent claudication, prolonged capillaries refill time more than 2 sec.

Question 26

What are the common conditions affecting the leg:

Answer 26

• Osgood schlauer syndrome
• Shin splints
• Stress fractures
• Calf strains: tennis leg, achilles tendonitis, tibias ant/post, perineal muscles.
• Compartment syndrome
• DVT

Question 27

Explain the pathophysiology of Osgood-schlatter’s syndrome:

Answer 27

• a traction apophysitis of the tibial tuberostiy in active children and young adolescents (males 10-15 years, females 8-13 years)
• Pain during walking up or down hills, stairs, kneeling
• three times more common in males than females
• caused by excessive traction on the soft apophysis of the tibial tuberosity by the patellar tendon
  associated with high levels of activity during a period of rapid growth

Key assessment findings for Osgood Schlatter’s disease

• Pain at the tibial tuberosity in a young active child or adolescent
• Palpation: pain and tenderness on palpation at the tibial tuberosity
• There may be local swelling

Question 28

What would be your treatment plan of Osgood SChlatter syndrome:

Answer 28

• Acute - RICE and rest/reduced participation in the responsible activity for at least two weeks
• Ice and taping to reduce the pull of the quadriceps on the tibial tuberosity
• Chronic – heat, ST, reduction of activity until the end of the rapid growth phase
• Avoid vigorous quadriceps stretching until the tibial tuberosity fuses to the tibia at about 16 years of age
• After fusion, stretching and strengthening quadriceps and hamstrings as required to restore normal knee biomechanics

Question 29

explain the pathophysiology of shin splints:

Answer 29

• pain due to repetitive overuse such as running or dancing
  long periods of standing on a concrete floor or other hard surface in hard soled shoes also implicated
  two main types of shin splints:
• Anterior/lateral shin splints: tibialis anterior strain, tendinopathy or periostitis - associated with excessive eccentric dorsiflexion (e.g. downhill walking or running)
• Posterior shin splints: tibialis posterior strain, tendinopathy or periostitis. Flexor digitorum longus and soleus may also be involved - associated with overpronation or incorrect running stride

Overview of treatment and management

Acute – RICE, rest from aggravating activities (such as exercise on hard, uneven surfaces), gentle stretching + other osteopathic techniques

Chronic - reduce hypertonicity in affected muscles + other osteopathic techniques

Question 30

Explain the pathophysiology of Compartment syndrome and signs and symptoms:

Answer 30

History of trauma, crush injury, or recent participation in rigorous unaccustomed exercise

Severe persistent leg pain that is aggravated by stretching the involved muscles

Swelling, exquisite tenderness and palpable tension/hardness of involved compartment

Paresthesia, paresis, absence of pulse

Question 31

Explain the pathophysiology of Osgood-schlatter’s syndrome:

Answer 31

• a traction apophysitis of the tibial tuberostiy in active children and young adolescents (males 10-15 years, females 8-13 years)
• Pain during walking up or down hills, stairs, kneeling
• three times more common in males than females
• caused by excessive traction on the soft apophysis of the tibial tuberosity by the patellar tendon
  associated with high levels of activity during a period of rapid growth

Key assessment findings for Osgood Schlatter’s disease

• Pain at the tibial tuberosity in a young active child or adolescent
• Palpation: pain and tenderness on palpation at the tibial tuberosity
• There may be local swelling

Question 32

What would be your treatment plan of Osgood SChlatter syndrome:

Answer 32

• Acute - RICE and rest/reduced participation in the responsible activity for at least two weeks
• Ice and taping to reduce the pull of the quadriceps on the tibial tuberosity
• Chronic – heat, ST, reduction of activity until the end of the rapid growth phase
• Avoid vigorous quadriceps stretching until the tibial tuberosity fuses to the tibia at about 16 years of age
• After fusion, stretching and strengthening quadriceps and hamstrings as required to restore normal knee biomechanics

Question 33

Explain the pathology of stress fracture:

Answer 33

• a hairline break that occurs without history of trauma
• chronic shin splints may be a precursor
  usually occurs after prolonged activity such as running, skiing or marching on a hard surface or in a hard-soled boot
• also occur from osteoporosis in female
• long distance runners
  diagnosis confirmed by X-ray or bone scan
• Most common in running sports
  25% incidence in athletes with lower leg
  pain
  Low bone mineral density imposes higher risk
  Overpronation places higher stress on the
  fibula and tibia

Question 34

Give an example of different compartment syndrome

Answer 34

Anterior compartment most common (tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneus tertius, tibial artery and vein, deep peroneal nerve)

In acute anterior compartment syndrome elevated pressure from tissue fluid/blood within the compartment causes ischemia
This is a medical emergency. Refer any client with persistent pain in the anterior leg with visible swelling or “stocking” numbness or tingling for immediate surgical decompression

Lateral compartment syndrome involves peroneus longus and brevis. May be associated with paraesthesia or a trickling pain on the outer lower border of the leg (due to compression of the superficial peroneal nerve usually from increased pressure in both the lateral and posterior compartments)

Question 35

As a practitioner how would you recognise the difference between shin splints, compartment syndrome and stress fracture.

Answer 35

Shin splints: Pain deceases as the muscle warms up, Pain worse in morning and after exercise, Palpatory tenderness over a wide region of the tibia and involved muscle, Pain anterolateral or posteromedial border tibia.

Compartment syndrome: Crampy ache, tightness, swelling in the legs. Anterior compartment - pain on dorsiflexion; lateral compartment – pain on eversion, Increases with exercise (can continue to increase for a short time after exercise), Occasionally muscle weakness or sensory symptoms, Tightness evident on palpation.

Stress fracture: Severe anterior shin pain
Acute, sharp, Constant, increasing with exercise Worse with impact, Night ache
May be worse in morning, palpation elicits localised pain.

Question 36

Describe Calf strain:

Answer 36

Gastrocnemius strain (tennis leg)
- older athletes (30 to 50 years)
- sudden onset of pain in medial head
- after a sudden explosive push off from a stationary position, climbing a slope or suddenly changing direction
- client sometimes reports a sudden stinging or popping sensation in the calf
- often associated with a cold environment
- tenderness in muscle belly approx. 5 cm
superior and medial to musculotendinous junction
- in severe cases muscle defects may be palpable

Question 37

Explain the physiopathology of DVT:

Answer 37

Deep venous thrombosis (DVT) is a manifestation of venous thromboembolism (VTE). DVT is the presence of coagulated blood, a thrombus, in one of the deep venous conduits that return blood to the heart. Venous stasis can occur as a result of anything that slows or obstructs the flow of venous blood. This results in an increase in viscosity and the formation of microthrombi, which are not washed away by fluid movement; the thrombus that forms may then grow and propagate. Thrombosis is the homeostatic mechanism whereby blood coagulates or clots, a process crucial to the establishment of hemostasis after a wound. It may be initiated via several pathways, usually consisting of cascading activation of enzymes that magnify the effect of an initial trigger event.
Thrombosis is the homeostatic mechanism whereby blood coagulates or clots, a process crucial to the establishment of hemostasis after a wound. It may be initiated via several pathways, usually consisting of cascading activation of enzymes that magnify the effect of an initial trigger event. Microscopic thrombus formation and thrombolysis (dissolution) are continuous events, but with increased stasis, procoagulant factors, or endothelial injury, the coagulation-fibrinolysis balance may favor the pathologic formation of an obstructive thrombus. Clinically relevant deep venous thrombosis is the persistent formation of macroscopic thrombus in the deep proximal veins.
For the most part, the coagulation mechanism consists of a series of self-regulating steps that result in the production of a fibrin clot. Once a fibrin clot is formed and has performed its function of hemostasis, mechanisms exist in the body to restore the normal blood flow by lysing the fibrin deposit. Circulating fibrinolysins perform this function. Plasmin digests fibrin and also inactivates clotting factors V and VIII and fibrinogen.
Three naturally occurring anticoagulant mechanisms exist to prevent inadvertent activation of the clotting process.

Question 38

What are the history of DVT:

Answer 38

History

• Recent surgery, malignancy, pregnancy, trauma or leg immobilisation (e.g. long plane or bus trip)
• Calf pain, oedema, tenderness, warmth
• Pain increases with standing or walking, relieved by rest and elevation
• Possible pallor and loss of dorsalis pedis pulse

Question 39

What are the diagnostic for DVT:

Answer 39

• Dx: doppler ultrasound, D-dimer blood test (for hypercoagulability), venography
• Serious complications include pulmonary embolism and postphlebitic syndrome
• Treatment consists of anticoagulant therapy, elevation of the limb, fibrinolytic therapy and sometimes thrombectomy

Question 40

What are the physical examination of the ankle:

Answer 40

• anterior and posterior draw test.
• Lateral ligament stability test.
• Tinel signs

Question 41

What are the common condition affecting the ankle?

Answer 41

• ankle sprain.
• achilles tendonitis
• Sever’s disease
• Achilles bursitis
• Ankle DJD

Question 42

Explain Grade 1 sprain ankle inversion:

Answer 42

Aetiology

• Occurs with inversion plantar flexion and abduction
• Causes stretching of the anterior talofibular ligament
• Signs and Symptoms
• Mild pain and disability; weight bearing is minimally impaired; point tenderness over ligaments and no laxity

Management
RICE for 1-2 days; limited weight bearing initially and then aggressive rehab
Tape may provide some additional support (proprioception)
Return to activity (FUNCTIONAL) in 7-10 days

Question 43

Explain Grade 2 sprain ankle inversion:

Answer 43

Aetiology
Moderate inversion force causing great deal of disability with many days of lost time

Signs and Symptoms
Feel or hear pop or snap; moderate pain, difficulty bearing weight; tenderness and edema
Positive talar tilt (lat lig stability test) and anterior drawer tests
Possible tearing of the anterior talofibular and calcaneofibular ligaments

Management
RICE for at least first 72 hours; X-ray exam to rule out #; crutches 5-10 days, progressing to weight bearing

Management (continued)

• Requires protective immobilization but begin ROM exercises early to aid in maintenance of motion and proprioception
• Taping for support during early stages of walking and running
• Long term disability can include chronic instability with injury recurrence potentially leading to joint degeneration
• Must continue to engage in rehab to prevent against re-injury
• Requires protective immobilization but begin ROM exercises early to aid in maintenance of motion and proprioception
• Taping for support during early stages of walking and running
• Long term disability can include chronic instability with injury recurrence potentially leading to joint degeneration
• Must continue to engage in rehab to prevent against re-injury

Question 44

Explain Grade 3 sprain ankle inversion:

Answer 44

Aetiology
Relatively uncommon but is extremely disabling
Caused by significant force (inversion) resulting in spontaneous subluxation and reduction

Causes damage to the anterior/posterior talofibular and calcaneofibular ligaments as well as the capsule

Signs and Symptoms
Severe pain, swelling, hemarthrosis, discoloration
Unable to bear weight
Positive talar tilt and anterior drawer

Management
RICE, X-ray (sometimes dorsiflexion splint for 3-6 weeks)
Crutches after cast removal
Isometrics in cast; later ROM, resistance and balance exercise
Surgery may be warranted to stabilize ankle if ankle unstable

Question 45

Explain eversion sprains:

Answer 45

Aetiology: 5-10% of all ankle sprain.
Bony protection and ligament strength decreases likelihood of injury
Eversion force results in damage to deltoid ligament and possible # fibula
Deltoid can also be impinged and contused with inversion sprains

Question 46

Can you describe the difference between grade 1, 2 and 3 from a practise point of view: What can you notice on the patient, signs and symptoms:

Answer 46

GRADE 1
No bruising, limited local aedema, one side of Achilles tendon
Localised tenderness, usually anterolateral
None or mild limp for up to 2 days, can rise up on toes slowly, painful hop
No joint laxity - -ve ligament stability tests, pain at extreme of movement
1-2 weeks to functional recovery; 1-2 months to structural recovery

GRADE 2
Bruise on one side of foot
More extensive oedema, Achilles contours identifiable but blurred
Less localised tenderness, both sides of ankle
Visible limp for 2-13 days, unable to rise up on toes, hop or run
Slight laxity when stressed, pain with most movement (esp. inv and plantar flexion)
1-2 months to functional recovery; 6-12 months to structural recovery

GRADE 3
Diffuse bruising and oedema on both sides of foot, loss of Achilles contrours
General tenderness on both sides of foot
Unable to bear weight, almost complete loss of movement
+ve laxity and stability tests. Rule out fracture (Ottawa rules)
2-6 months to functional recovery; 1 year+ to structural recovery

Question 47

Can you explain the Ottawa ankle rules:

Answer 47

Radiographs are indicted with any one of the following criteria following traumatic ankle/foot injury
Patient over 55 years
Patient unable to bear weight for 4 consecutive steps (2 with each foot)
Localised tenderness along posterior aspect of lateral or medial malleolus (anterior or inferior tenderness not correlated with fracture)
Localised tenderness along crest of lateral or medial malleolus (where side of malleolus joins shaft) (Buffalo rule)
Localised tenderness over navicula, cuboid, or 5th metatarsal
(Does not apply to children under 5 years, pregnant women, and those with diminished ability to follow tests)

Question 48

Name the mechanoreceptors found in the skin muscles and joints:
receptor type, location, respond to and time to adapt:

Answer 48

Pacinian: dermis, pressure and vibration up to 2 cm away from body, rapid
Meissners: superficial dermis, surfaces changes, rapid.
Merkel discs: fingers and toes epidermis, pressure texture and tissue displacement, slow.
Ruffini ending: dermis, movement changes as little as two degree, rapid.
Krause end bulbs: dermis, thermal receptors adapting to any receptor type, variable.
Free nerve endings: superficial, temperature and pain, very rapid.
Golgi tendon organs: tendons and cruciate ligaments, tension muscle, rapid.
Muscle spindle cells: type 2, muscle length and rapid.

Question 49

Explain the physiopathology of Sever’s disease, treatment and management, signs and symptoms:

Answer 49

a common foot problem in active children aged 8 to 15 years
a traction apophysitis at the Achilles insertion into the calcaneus that often occurs during rapid growth spurts when bone growth can cause muscles and tendons to become tight
can become chronic and persist until about 16 years of age
Predisposed if pronating foot, flat or high arch, short leg, overweight or obese.
Signs and symptoms

Swelling and redness in the heel
Difficulty walking
Discomfort, stiffness in feet when first wake up
Discomfort when heel is squeezed on both sides
Unusual gait (e.g. limp, on tiptoes)

Treatment and management
reduce the level of physical activity for one to two weeks
ice application after exercise may help control inflammation
shoes should be replaced when they become too small or if the heel counter is too tight
restore muscle balance, especially gastrocnemius, soleus and tibialis anterior

Question 50

Explain the pathophysiology of bursitis:

Answer 50

usually from direct rubbing from shoes with upper border heel counter too tight, too loose or convex
can also follow a direct impact on the heel
Bursitis is defined as inflammation of a bursa.
Inflammation of the bursa causes synovial cells to multiply and thereby increases collagen formation and fluid production. A more permeable capillary membrane allows entrance of high protein fluid. The bursal lining may be replaced by granulation tissue followed by fibrous tissue. The bursa becomes filled with fluid, which is often rich in fibrin, and the fluid can become hemorrhagic. [8] One study suggests that this process may be mediated by cytokines, metalloproteases, and cyclooxygenases. There are three phases of bursitis: acute, recurrent, and chronic. [9] During the acute phase of bursitis, local inflammation occurs and the synovial fluid is thickened, and movement becomes painful as a result. Chronic bursitis leads to continual pain and can cause weakening of overlying ligaments and tendons and, ultimately, rupture of the tendons.

Treatment
RICE
heel pad may protect the area from further rubbing
avoid wearing the offending shoes

Question 51

Explain DJD ankle

Answer 51

common in older patients or those with significant previous trauma
Complain of limited range of motion and chronic pain aggravated by weight bearing
Assessment
Capsular pattern: limited dorsiflexion
Crepitus
Hard end-feel

Treatment
Osteo techniques to restore normal biomechanics
Advice regarding weight loss, appropriate footwear, home exercise, supplements etc