LEG, ANKLE & FOOT INJURIES Flashcards
Sources of leg pain: common, less common & no to be missed
Tableau
Common source of ankle pain: common, less common & not to be missed
Tableau
Interrelationship between sources of leg pain
Schema
TENDINOPATHIES: mechanism
Schema
≠ grading of ligament injuries
Grade I (disruption of some fibres):
Localised tenderness on palpation, minimal inflammation, normal end ROM & end feel (no laxity), but could have pain on movement
Grade II (disruption of moderate number of fibres):
Significant tenderness on palpation, considerable inflammation over whole joint, increased laxity on testing, but definite end point
Grade III (complete disruption of fibres):
Audible ‘pop’ during injury, often immediately painful, but then pain-free rapidly, severe swelling (possible haemarthrosis), significant laxity with no end point
≠ grading of muscle tears
Grade I (mild):
Usually patient able to continue activity
Minimal loss of ROM & strength
Very small amount of muscle finders disrupted ( < 10%)
Grade II (moderate):
Patient find difficult to walk Muscle fibers disruption 10%- 50%
Grade III (severe):
Palpable defect present
Complete disruption of muscle continuity Muscle fibers disruption about 50% -100%
MEDIAL TIBIAL STRESS SYNDROME:description, pathophysio, risk factors, signs & symptoms, assessment
D: - Exercise induced pain at distal 2/3 of medial posterior tibial border
- Affects up to 20% of runners, dancers
- Females ↑ risk
- Military personnel
P: - Periostitis, induced by fascial traction
- Local bone stress reactions
- Cortical bone micro-trauma (in most cases)
- Dysfunction of Anterior & Posterior tibialis muscle, Soleus & FDL important
RF: - ↑ BMI (Body Mass Index) - ↑ Pronation
- Previous running injury - ↑Hip Ext or Int rotation
- Female
- Training errors - Shoe design
S&S: - Diffuse pain along distal 2/3 of posteriomedial border - Tenderness on palpation (TOP) on middle distal tibia for several days , following activity
- Pain & TOP usually spread over area of 5cm
- Early stages of MTSS : Pain ++ at beginning of exercise & decreases with warm-up
- Later stages: pain present even during rest
A: - Based on careful assessment of alignment & gait biomechanics
- Muscle strength, length & endurance assessment of triceps surae
- Foot arch abnormalities (high vs low arch, dynamic vs static?)
- Leg length discrepancies
Chronic exertional compartment syndrome: description, pathophysio, sign& symptoms, assessments
D: Increased pressure in closed fibre-osseous space
- Reduced blood flow & reduced tissue perfusion
- Typically in endurance athletes (runners) - Frequently bilateral
P: Pathogenesis is unclear
- Repetitive overuse leading to inflammation & fibrosis
- Reduced fascial elasticity due to fibrosis
- Pain when doing exercise & muscles attempt to expand within fascia
S&S: Symptoms
- No pain at rest
- Ache/pain & feeling of tightness increasing with exertion
- Symptoms resolve within minutes of stopping
- Rare: parasthesia/motor weakness with exertion
Signs
- Compartment tense on palpation No special tests:
- Limb & foot alignment
- Training surfaces/shoe assessment
- Intra-compartmental pressure measurements
A: OBJECTIVE:
- Length of soleus & gastrocnemius
- Palpation of compartment: normal on palpation
- Biomechanical assessment of pelvic/hip/ knee control while running
Achilles tendinopathy: description, risk factors, signs & symptoms, assessment
D: Typically mid portion Achilles tendinopathy (rare: insertional)
- Common in running & jumping sports. Highest incidence in runners, tennis, soccer, volleyball players
- Usually following increase in training load volume/intensity
RF: Intrinsic
- ↑ BMI index
- Systemic condition: DM, hypercholesterolaemia, inflammatory arthritis
- Fluroquinolones or steroid medication
- Older age but usually load related
- Biomechanically: PF weakness, excess DF, decreased DF, knee flexor weakness, poor quality tendon, supinated & rigid foot
Extrinsic
- Change loading:increased distance, speed or frequency of training
- Sudden increase in explosive activities like jumping/landing
- Change in foot wear or training surface
SS: Gradual onset
- Morning stiffness/pain (eases with mvt) - Pain with tendon palpation, 2-6cm above distal insertion (Posterior heel)
- Possible tendon thickening
- Pain with resisted P/F & stretching
- Pain & stiffness following activity (hours later/following morning)
A: OBJECTIVE:
- No special tests: hypothesis based on signs, symptoms & physical examination
- Symmetry between muscle & tendon on observation?
- Palpation: tendon thickening/ pain
- Calf raises: for pain response/endurance
- Hopping: pain response
- Biomechanics: DF (WB lunge test), gastrocnemius vs soleus
- VISA-A outcome measure
Achilles tendon rupture: description, signs & symptoms & assessment
D: Sudden onset injury
- Sports related: mainly tennis, football, downhill skiing
- Mechanism of injury: frequently includes pushing off with weight bearing forefoot with knee extended
- Multifactorial cause:
- Intrinsic (biomechanical issues) & extrinsic factors (shoes, surface training, training errors…)
S&S: - Sudden & loud snap
- Subject unable to continue activity - Bruising and swelling
- Weak PF
A: Special Test: +ive Thomson Squeeze Test
Gastrocnemius tears / strains: description, pathophysio, signs & symptoms, assessment
D: Sudden onset of pain
- Medial head of gastrocnemius most commonly injured
- Common in middle aged or older patients
- Common in younger athletes playing tennis & other sports
P: Mechanism of injury
- Running or jumping.
- Eccentric ankle dorsiflexion with knee in extension
- Excessive stretch & rapid forceful contraction of muscle
S&S: Immediate pain
- Swelling depending on grade
- Patient unable to walk due to intense pain (depends on grade)
- Tenderness in muscle tear site (medial belly of muscle)
- Palpable defect
A: OBJECTIVE:
- Observation: walk with a limp (antalgic gait), bruising or swelling present
- Palpation: palpable defect on Gr III tear - Pain on active and passive DF
- Pain on resisted PF with knee extended
Lateral collateral ligament injuries: description, signs & symptoms & assessment
D: - Anterior Talofibular Ligament (ATFL) – 90% of all LCL injuries
- Calcaneofibular Ligament (CFL) – usually occur after/together with ATFL
- Posterior Talofibular Ligament (PTFL) – rare, usually only with dislocation
S&S: Sudden onset
- Pain on lateral side
- ↓ ROM overall
- Swelling: usually rapid but can be delayed (on lateral side)
- MOI: inversion+ PF or neutral or DF
A: SPECIAL TESTS: Testing 4 to 5 days after injury results in more accurate diagnosis - Anterior drawer test
- Talar tilt test
Medial collateral lig injuries: description, signs & symptoms
D: Often due to direct (player) contact
- Forceful eversion
- Frequently associated with syndesmotic injuries (High ankle sprain)
S&S: Pain on medial side
- ↓ ROM overall
- Swelling: usually rapid but can be delayed (on medial side)
Syndesmosis injuries: description, pathophysio, sing & symptoms, assessment
D: = high ankle sprain
- Present in 13% of all ankle fractures
P: - Mainly associated with External rotation stress & dorsiflexion of foot which leads to displacement of fibula & tear in syndesmosis - Large forces lead to fibula fractures
S&S: - Pain on palpation over tibiofibular ligaments - Bruising more proximal than LCL injuries
- Feeling of instability especially in weight bearing
A: Special tests: Syndesmosis squeeze test, external rotation test
May take double time to rehab compared to lateral ankle sprains
- X-ray commonly used for diagnosis
Sinus tarsi syndrome: description, risk factors, signs & symptoms, assessment
D: = lateral ankle pain
- Inflamed tissue inside Sinus Tarsi tunnel (cervical ligament & root of inferior extensor retinaculum)
RF: Increased mobility of talocrural & subtalar joints following repeated ankle sprains
S&S: - Gradual onset of pain following instability or acute ankle sprain
- Pain on anterolateral aspect of ankle
- Instability sensation on foot inversion & eversion - End range pain with passive inversion & eversion - Often severe pain in morning which improves on warming up
A: Subjective information:
- HOPC: injury mechanism (plantar flexion with supination/inversion)
- PMH: Previous ankle injury, ankle instability
- Aggr: Running on unstable surfaces
Objective information:
- Lower limb alignment: Standing posture (high arch vs low arch)
- Anterior/posterior glides of ankle
- Talar tilt test
