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Lower Extremity Injuries Flashcards

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1
Q

How should a suspected PROXIMAL FEMUR FRACTURE be managed ACUTELY?

A
  • MEDICAL EMERGENCY
  • Call EMS
  • Treat for shock
  • Splint before moving them
  • test neurovascular structures periodically
  • most require surgery
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2
Q

If an acetabular fracture is missed - what can result?

A
  • Avascular necrosis of the femoral head
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3
Q

What would prompt URGENT HOSPITALIZATION with a Traumatic PELVIC FRACTURE?

A
  • Disruption of the pelvic ring
  • Abdominal organ injury or Hemorrhage

*no disruption of ring = treat based on symptoms

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4
Q

What is a test used to diagnose Femoral shaft Stress Fractures?

A
  • FULCRUM TEST (assessor’s arm under thigh; pushes superior to inferior at distal thigh; +ve = pain and apprehension)
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5
Q

What types of femoral stress fractures are HIGH RISK? How are they treated?

A
  • LATERAL FEMORAL NECK
  • FEMORAL HEAD
  • Surgical Stabilization OR STRICT non-weightbearing (until callous forms)
  • typically occur at neck and are due to COXA VARA
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6
Q

What is the typical TREATMENT for LE STRESS FRACTURE?

A
  • PROPER diagnosis is important
  • refer to MD
  • Weight bearing restrictions (Non or limited)
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7
Q

What is the typical CAUSE of Lower Extremity APOPHYSITIS? What are expected RTP timeframes?

A
  • Chronic traction forces

- RTP =2-6 months (~3.1 month average)

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8
Q

How should an uncomplicated ACUTE AVULSION fracture in the lower extremity be treated?

A
  • TTWB for 1-2 months
  • gradual progression of strengthening and stretching of impacted muscle as tolerated
  • if displaced - may need surgery
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9
Q

What anatomical factors increase the prevalence for hip LABRAL pathology?

A
  • Coxa Vara
  • increased center-edge angle (measures anterior coverage of femoral head by acetabulum)
  • Retroverted femur
  • Retroverted acetabulum
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10
Q

How should LABRAL PATHOLOGY of the hip be managed ACUTELY?

A
  • REST
  • Protected weightbearing
  • avoiding TRANSVERSE plane movement
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11
Q

What are some DIFFERENTIAL DIAGNOSES for FAI?

A
  • Osteitis pubis
  • Athletic Pubalgia
  • Lumbosacral Pathology
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12
Q

Does FAI typically present with palpatory tenderness?Weak hip flexors and abductors?

A
  • No

- Yes

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13
Q

What are some STRUCTURAL DEFORMITIES that can contribute to hip instability?

A
  • Shallow acetabulum (contributes to labral tears)
  • Excessive acetabular retroversion or anteversion
  • Inferior acetabular insufficiency
  • Neck-shaft angle >140 deg (coxa valga)
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14
Q

What is FOCAL ROTARY INSTABILITY of the hip?

A
  • Laxity at ligamentous (often iliofemoral ligament) or capsular structure DUE TO repeated forceful rotation at hip (i.e.: golf, ballet, martial arts, baseball)
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15
Q

What is the most common direction of HIP DISLOCATION? What is the MOI?

A
  • ~85% POSTERIOR

- MOI = ant to posterior force on flexed and adducted hip

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16
Q

How should a HIP DISLOCATION be managed ACUTELY?

A
  • EMERGENT reduction (avoid Osteonecrosis)

* evaluate neurovascular status of leg (cutaneous nerve function, distal pulses - popliteal and dorsalis pedis)

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17
Q

What is the HIP APPREHENSION sign? What is it used for?

A
  • Passively EXTEND, ABDUCT, EXTERNALLY ROTATE = may report sensation of instability
  • to test for atraumatic hip instability (hip is typically unstable in the posterior direction which is the most common direction)
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18
Q

What activities or movements should the athlete with hip instability avoid?

A
  • FORCEFUL HIP EXTENSION
  • FORCEFUL ROTATIONAL LOADING

*these movements stress passive restraints

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19
Q

What are some SPECIAL TESTS to determine atraumatic HIP INSTABILITY?

A
  • FABER
  • FADIR
  • HIP IR >30 deg at 90 deg flex
  • hip APPREHENSION sign
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20
Q

What are some PRIMARY treatment focuses with REHAB for patients with atraumatic hip instability ?

A
  • FOCUS ON NEURO RE-ED

- STRENGTHEN HIP ABDUCTORS AND ROTATORS (to assist in supporting limited passive restraints)

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21
Q

Severe hip flexor injuries can lead to profound swelling which can cause what?

A

FEMORAL NERVE PALSY

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22
Q

What can be predictive for adductor strains?

A

Relative strength deficits between hip abductors and adductors

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23
Q

What is the most commonly injured hip adductor muscle?

A
  • ADDUCTOR LONGUS

* has excellent blood supply - can rehab aggressively

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24
Q

What muscles are indicated in ATHLETIC PUBALGIA (sports hernia)?

A

PUBIC ATTACHMENTS OF:

  • RECTUS ABDOMINUS
  • HIP ADDUCTORS

*often attributed to imbalance - strong adductors and weak abdominals

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25
Q

Some ATHLETIC PUBALGIA signs and symptoms include…?

A
  • intense, deep groin/lower abdominal pain
  • worse with: SPRINTING, CUTTING, RESISTED SIT UP TEST
  • pain with RESISTED ADDUCTION and PALPATION TO PUBIC RAMIS
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26
Q

What are SURGICAL OPTIONS for ATHLETIC PUBALGIA?

A
  • ABDOMINAL WALL REPAIR
  • ADDUCTOR TENOTOMY
  • rehab starts ~4 weeks post op
  • avoid trunk extension and rotation to protect surgical site
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27
Q

What is the difference between INTERNAL and EXTERNAL SNAPPING HIP SYNDROME?

A
  • INTERNAL = iliopsoas tendon snaps over iliopectineal eminence OR femoral head
  • EXTERNAL (most common) = IT band or GLUTE MAX snaps over greater trochanter (sagittal and transverse movements)
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28
Q

For patients with EXTERNAL SNAPPING HIP, what muscle tends to be overactive AND what muscle tends to be underactive?

A
  • Overactive = TFL
  • Under active = Glute max

*Have been shown to glute eccentric weakness

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29
Q

What chance do partial ACL ruptures >50% have of complete rupturing?

A

> 50% chance of progression to full rupture

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30
Q

At what point post ACL RECONSTRUCTION can you initiate jogging, hopping, jumping? What criteria must be met?

A
  • 12 weeks
  • STRENGTH AND ROM NORMALIZED
  • NO LAXITY PRESENT - graft is secure
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31
Q

What is the MOI for the entire MCL (deep and superficial fibers)? What is the MOI for the SUPERFICIAL MCL?

A
  • Entire MCL = knee extended

- Deep fibers = knee flexed >20 deg

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32
Q

Injury to the deep fibers of the MCL are associated with what other structures?

A

ACL, medial meniscus, bone bruise, or osteochondral injury

*Deep fibers attach to medial joint capsule and medial meniscus

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33
Q

When valgus stress testing the MCL, what is the difference in laxity between grades 2-1+, 2-2+ and 3?

A 
2-1+ = 0-5 mm laxity, end feel present
2-2+ = 5-10 mm laxity, end feel difficult to determine
3= no end feel (complete rupture)
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34
Q

How are MCL tears treated? What is the timeline for RTP?

A
  • Almost exclusively treated CONSERVATIVELY
  • get terminal KNEE EXTENSION ROM ASAP
  • RTP = grade 1 = 7-10 days
    Grade 2 = up to 3 weeks
  • can brace (PT, MD dependent)
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35
Q

What is the POSTEROLATERAL COMPLEX region of the knee made up of?

A
  • POSTERIOR JOINT CAPSULE
  • LCL
  • POPLITEUS TENDON
  • POPLITEOFIBULAR LIGAMENT
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36
Q

What are some tests to aide in DIAGNOSIS of POSTEROLATERAL COMPLEX injuries?

A
  • Knee Varys Test (laxity)
  • Dial Test (laxity)- prone, flex knees, rotate tibias
  • ER Recurvatum Test of Hughston (laxity)
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37
Q

What is the MOI for PCL injury?

A
  • HYPERFLEXION

- BLOW TO FRONT OF KNEE (TIBIA) WHILE KNEE FLEXED (dashboard)

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38
Q

What do POSTEROLATERAL COMPLEX injuries usually occur in conjunction with?

A
  • LCL sprains

- cruciate sprains

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39
Q

What are 3 tests to determine injury to the PCL?

A
  • posterior sag sign
  • posterior drawer test
  • Clancy Step off test (thumbs palpate femoral condyle, IP joints palpate tibial plateau - which should be 1 cm in front of condyles; any deviation = positive)
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40
Q

What is the BIGGEST concern following PCL injury?

A
  • RESIDUAL TIBIAL LAG (after reconstruction and surgery)

* Avoid hamstring exercises the first 6-8 weeks

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41
Q

How is a DISLOCATED patella (usually laterally) RELOCATED?

A
  • MOVING FLEXED KNEE INTO FULL EXTENSION (ACTIVELY OR PASSIVELY)
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42
Q

How should a DISLOCATED PATELLA be managed ACUTELY?

A
  • IMMOBILIZE
  • ICE
  • TRANSFER for imaging (due to risk for fracture or osteochondral injury)
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43
Q

What are BRACING recommendations post LATERAL PATELLA DISLOCATION?

A
  • Immobilize 3-4 weeks

- post immobilization - progress to less restrictive brace with LATERAL BUTTRESS (limits lateral translation)

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44
Q

What is SURGICAL treatment of choice for LATERAL PATELLAR DISLOCATION if conservative treatment fails?

A
  • MPFL repair or reconstruction
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45
Q

Why is a TIBIOFEMORAL DISLOCATION considered a medical emergency?

A
  • Close proximity of NEUROVASCULAR structures in POPLITEAL FOSSA
  • Can result in: vascular issue (loss of limb), or inability to walk (neurological compromise)
  • IMMOBILIZE AND TRANSPORT
  • sometimes it may REDUCE spontaneously = makes it difficult to diagnose
  • if 3 or more ligaments have been injured = knee should be considered DISLOCATED (regardless of alignment)
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46
Q

What are signs and symptoms of TIBIOFEMORAL DISLOCATION acutely?

A
  • Extreme pain
  • Significant swelling
  • Shock - WATCH FOR IT
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47
Q

How should TIBIOFEMORAL DISLOCATION be managed ACUTELY?

A

ACUTELY:

  • Call EMS; Monitor neurovascular status (popliteal pulse, peroneal and tibial nerves)
  • immobilize in EXTENSION for at least 4 weeks
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48
Q

How does knee MENISCAL injury type present differ as it’s related to AGE of the patient?

A
  • YOUNGER = meniscus (with ACL) = peripheral injury (more likely to heal intrinsically)
  • OLDER = tears in less vascular area = less amenable to repair
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49
Q

What are the RTP recommendations post partial meniscectomy ?

A
  • ~6-8 weeks

* usually WBAT as tolerated immediately (no brace required)

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50
Q

What are the post-surgical requirements regarding weight-bearing status and brace use post MENISCUS REPAIR? What are ROM and strengthening restrictions? What is RTP timeline?

A
  • ~4-6 weeks brace (locked into extension - depending on type and repair); WBAT or PWB (depending on repair, surgeon)
  • flexion ROM <90 deg (first 6 weeks)
  • strengthening progress as tolerated at 6 weeks
  • RTP = 16-20 weeks
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51
Q

Differentiate between the 4 grades of OSTEOCHONDRAL INJURIES.

A
  • Grade 1 = softening, swelling of cartilage
  • Grade 2 = fissuring, fragmentation <0.5 inch
  • Grade 3 = fissuring, fragmentation >0.5 inch
  • Grade 4 = erosion down to subchondral bone
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52
Q

What are the signs and symptoms of OSTEOCHONDRAL INJURIES?

A
  • PAIN and SWELLING with activity that relieves with rest
  • no SPECIAL TESTS (best DX via radiographs, scope)
  • symptoms may be MINOR until defect comes loose
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53
Q

What are the SURGICAL OPTIONS for OSTEOCHONDRAL INJURIES?

A
  • Microfracture
  • Osteochondral Autologous/Allograft Transplantation (OATs)
  • Autologous Chondrocyte Implantation
  • Debridement
  • Lavage
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54
Q

What are the REHAB PRECAUTIONS post surgical intervention for OSTEOCHONDRAL injuries?

A
  • Limited WB 4-6 weeks post (except with posterior patella, or in trochlear groove - can WBAT with brace in full extension)
  • LOAD GRADUALLY
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55
Q

What is the path of the patella during knee movement from extension to flexion?

A
  • TRANSLATES slightly medial as it enters the femoral condyles @20-30 deg flexion
  • follows femoral condyle and TRANSLATES slightly laterally within the groove as it moves into greater flexion
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56
Q

What are some common activities that may EXACERBATE SYMPTOMS for those with PFPS?

A
  • SQUATTING
  • STAIRS
  • KNEELING
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57
Q

How much should a PATELLA be able to be MEDIALLY TILTED?

A

15 deg past neutral

58
Q

For what patient population would FOOT ORTHOSES be more effective in the treatment of PFPS?

A
  • OLDER patients
  • Those with FOREFOOT VALGUS or REARFOOT EVERSION

*Exercise may be better for YOUNGER patient

59
Q

Why is it important to control KNEE PAIN?

A
  • Pain inhibits QUAD muscle firing patterns
  • Can lead to QUAD atrophy and loss of ROM
  • Cryotherapy = effective at controlling pain
  • Cryo + compression may be best method
60
Q

What are the effects of INTRA-ARTICULAR EFFUSION on the KNEE joint and the surrounding musculature?

A
  • inhibits QUAD muscle firing patterns
  • detrimental effects on CARTILAGE (cartilage loss)
  • irritation to the SYNOVIUM
  • COMPRESSION = best for controlling/decreasing joint swelling
  • E-STIM = immediately after injury = decreases edema
61
Q

Why is it best to achieve JOINT (KNEE) ROM as soon as possible?

A
  • Joint immobilization = results in fibrous adhesions in and outside of the joint = increases friction between soft tissue fibers and layers
62
Q

What types of MENISCUS TEARS require a period of NON-WEIGHTBEARING post surgery?

A
  • RADIAL TEAR
  • DOUBLE RADIAL TEAR

*Non-WB = due to pattern of tear

63
Q

With PROPRIOCEPTIVE AND NEUROMUSCULAR CONTROL exercises, what are some changes to increase complexity and challenge?

A
  • Balance boards: double to single leg progression (differing planes of instabiity)
  • INTERNAL PERTURBATIONS = moving uninvolved LE in different directions
  • EXTERNAL PERTURBATIONS = resist force of perturbation, or regain balance after application of perturbation
  • DISRUPTING CONSCIOUS THOUGHT = toss or kick ball while balancing
64
Q

What is a FUNCTIONAL TESTING ALGORITHM regarding RTP?

A
  • Clinical decision making model
  • describes and evaluates OBJECTIVE DATA to determine readiness to progress to various stages of tests
  • Allows full, safe, expedient return to sports

*Goal is to identify DEFICITS so they can be addressed

65
Q

S/p ACL rehab - for RTP testing, how should Jump Testing be performed initially (single or double leg)? Why?

A
  • Double leg
  • WHY? = to shield affected side AND for increased comfort level

*ECCENTRIC LANDING stresses them most psychologically

66
Q

What is the BROAD JUMP TEST criteria for progressing to single leg unilateral hop tests?

A 
Male = jump 90-100% of their height
Female = jump 80-90% of their height
67
Q

What is the criteria for successfully passing a BROAD UNILATERAL HOP TEST?

A 
Male = jump 80-90% height
Female = jump 70-80% height

*AFFECTED LIMB should be within 10% of uninvolved limb

68
Q

The LOWER EXTREMITY FUNCTIONAL TEST is utilized with RTP testing because it incorporates what factors?

A
  • Progressive stress
  • Acceleration Deceleration movements
  • Has multiple forms of physical stress to the LE
  • Simulates varied movements often seen in reactive sports
  • Induce fatigue during testing

*LEFT= has been shown to identify deficits in pre-season injury screening

69
Q

What are the most common sites for fracture in: the ankle, the foot, the mid foot, hind foot?

A
  • ANKLE = bimalleolar
  • FOOT = metatarsals (5th most often)
  • MIDFOOT = cuboid
  • HINDFOOT = calcaneus
70
Q

What is a Maisonneuve fracture?

A
  • Proximal fibula fracture with INTERROSEUS MEMBRANE and SYNDESMOSIS tearing
71
Q

What are the Ottawa Midfoot Rules?

A

Radiographs are recommended if athlete has pain in mid foot and one of the following:

  • TTP at navicular
  • TTP at base of 5th metatarsal
  • inability to bear weight (<4 steps)
72
Q

What are the Ottawa Ankle Rules?

A

Radiographs are recommended if athlete has pain in malleolar zone and one of the following:

  • TTP at posterior edge of lateral malleolus
  • TTP at posterior edge of medial malleolus
  • Inability to bear weight (<4 steps)
73
Q

What is a common MOI for METATARSAL FRACTURE in sport?

A
  • TWISTING
74
Q

What METATARSAL, when fractured, may be at risk for delayed or non-union?

A
  • 5th METATARSAL
  • at metaphysic-diaphysis junction = watershed area AND due to biomechanics of transition between mobile diaphysis and rigid metaphysis
75
Q

Differentiate the 3 zones of 5th metatarsal fracture

A
  • Zone 1 = avulsion fracture of tuberosity (pull of peroneus brevis or lateral band of plantar fascia)
  • Zone 2 = @ metaphysic-diaphysis junction
  • Zone 3 = @ proximal diaphysis region (acute excessive load, or chronic loading = stress fracture)

*Operative management for 2 and 3 = best for athletic demand

76
Q

How should a non-displaced metatarsal fracture be managed?

A
  • 2-5 days in a cast

- 2-4 weeks in a walking boot

77
Q

How should a Jones fracture (Type 2 at metaphysic-diaphysis junction) be managed?

A
  • conservative = non-WB in short leg cast for 8-10 weeks

- surgical fixation recommended for athletes

78
Q

What types of metatarsal fractures should be surgically fixated?

A
  • those with >3-4 mm displacement OR >10 deg angulation

* use of SHOCKWAVE or ELECTROMAGNETIC waves may enhance healing

79
Q

What are RTP mean timeframes for : METATARSAL FRACTURE, ORIF 5TH METATARSAL, and NON-OP 5TH METATARSAL?

A
  • 4.6 weeks
  • 4-18 weeks
  • 9-22 weeks
80
Q

What is the most common site of lower limb stress fracture in runners?

A
  • TIBIA (followed by femur, fibula, calcaneus)
81
Q

What are signs and symptoms of STRESS FRACTURE?

A
  • PAIN - during or after activity (relieves with rest initially)
  • PAIN with ambulation (as injury progresses)
  • PALPATORY PAIN
  • LOCALIZED SWELLING
82
Q

How should a LE STRESS FRACTURE be managed?

A
  • LOAD and/or STRESS MODULATION (modified WB, and/or use of stabilizing orthotic depending on location)
  • EDUCATE (i.e., nutrition, training volume, footwear/orthotics)
  • CROSS TRAINING (to maintain CV fitness - V02 max 7% decline in first 2-3 weeks of stopping training)
  • ADDRESS strength, ROM, flexibility deficits
83
Q

What is a commonly accepted guideline for PROGRESSION or REGRESSION of an Athlete along a rehab/return to activity guideline?

A
  • Presence or Absence of PAIN
84
Q

When can RUNNING be initiated post LE STRESS FRACTURE? What VOLUME should be utilized when initiating running? What is a common PROGRESSION guideline?

A
  • RUNNING PROGRESSION may be initiated once pain-free ADLs
  • initiate with 1/3 to 1/2 of ATHLETES usual running distances and pace
  • start with walk/run intervals (longer walking and progress to longer running)
  • 10% progression per week

*Some recommend CYCLICAL TRAINING PROGRESSION (2 weeks higher level training to stress bone, 1 week reduced loading to allow for recovery)

85
Q

What are typical RTP timeframes s/p LE STRESS FRACTURE?

A
  • between 2-5 months (depending on severity and risk)
86
Q

What are some PREVENTATIVE measures to protect against LE STRESS FRACTURE?

A
  • IDENTIFY and CORRECT ENERGY BALANCE (nutrition, training workload, and rest days)
  • GRADUAL ramping of weight bearing activity/training
  • ORTHOTICS (custom fit or rigid)
87
Q

What is the STEP TEST and what is it used to assess?

A
  • assesses for STRESS FRACTURE RISK
  • TEST = complete 30 step up/down reps per min
  • 5 min = PASS
  • if FAIL = 76% increase incidence of LE stress fracture OR 35% increase incidence in MSK injury
88
Q

What is MEDIAL TIBIAL STRESS SYNDROME attributed to?

A
  • BONY OVERLOAD or…

- TRACTION periostitis at distal 2/3 of posteromedial tibia

89
Q

How is MTSS managed?

A
  • REST
  • GRADUAL activity/running PROGRESSION
  • MODIFY risk factors (nutrition, workload, rest days)
  • MODIFY RUNNING MECHANICS
  • ORTHOTICS (for those with excessive navicular drop)

*Recovery can be long, and recurrence rate HIGH

90
Q

Where is the most common OC lesion in the ankle?

A
  • TALUS (lateral > medial)
  • can occur in up to 50% of ankle sprains
  • non-traumatic (OC dessicans) can be from localized ischemia or repetitive micro trauma
91
Q

With what athletes, injuries should a TALAR OC LESION be considered?

A
  • recent ANKLE SPRAIN or FRACTURE

- CHRONIC ANKLE INSTABILITY

92
Q

What are signs and symptoms of TALAR OC LESION?

A
  • pain and swelling with activity
  • maybe limited ROM
  • maybe locking, catching if displaced fragment
  • if CHRONIC = deep ankle pain during or after loading activity (running, jumping)
93
Q

How are TALAR OC LESIONS managed?

A
  • NON-OP = rest, immobilization, Non WB ~6 weeks, gradual return to activity/WB
  • PRP injections = shown to be effective
  • OPERATIVE = micro fracture, ORIF, OATS, ACI
94
Q

What is a common MOI for TURF TOE?

A
  • INJURY to first MTP joint

- MOI = HYPEREXTENSION of MTP (axial loading with ankle and first MTP in plantar flexed position)

95
Q

What is the MOI for a High Ankle Sprain/Syndesmosis sprain?

A
  • FORCEFUL IR of LOWER LEG over PLANTED FOOT with foot DORSIFLEXED and PRONATED
  • isolated tears uncommon = usually with FRACTURE of one or more ankle bones
96
Q

What are special tests for High Ankle Pain/Syndesmosis joint injuries?

A
  • Squeeze Test (30% sen, 93.5% spec)
  • External Rotation Test (20% sen, 84.5% spec)
  • when POSITIVE = HIGHLY LIKELY
  • SINGLE LEG HOP TEST (89% sen)
  • “PAIN OUT OF PROPORTION FOR THE APPARENT INJURY” (79% spec)
97
Q

Which SYNDESMOSIS injuries require surgical fixation? What is the RTP timeframe?

A
  • Grade IIb (unstable) >2mm diastasis
  • Grade III
  • RTP typically ~9 weeks
  • undertreatment can result in CHRONIC hindfoot valgus, chronic lateral tibiotalar overload
98
Q

What are the signs and symptoms of MEDIAL ANKLE LIGAMENT INJURY?

A
  • reported MOI (combined pronation and eversion, excessive ER of foot)
  • Pain, swelling, hematoma over medial ankle
  • TTP over medial ligaments

*uncommon to occur independently

99
Q

What other injuries are MEDIAL ANKLE LIGAMENT injuries often associated with?

A
  • MEDIAL and/or LATERAL MALLEOLUS FRACTURE
  • HIGH FIBULA FRACTURE (MASIONNEUVE)
  • SYNDESMOSIS INJURY
  • LATERAL ANKLE LIGAMENT INJURY
100
Q

What TEST is used to assess extent of JOINT INSTABILITY following medial sided ankle injury?

A
  • EXTERNAL ROTATION STRESS TEST (gold standard) - stabilize tibia and externally rotate forefoot = look for amount of medial widening of ankle mortise
  • use STRESS RADIOGRAPHY
101
Q

What is the difference between Grade 2 and Grade 3 lateral ankle sprains?

A
  • Grade 2 = ATFL involved only, >5 deg (<10 deg) loss in total ankle ROM, swelling <2 cm
  • Grade 3 = ATFL and CFL +ve, >10 deg loss in total ankle ROM, swelling >2 cm
102
Q

After an initial ankle sprain - how long after is recurrence high? What can be the result of recurrence?

A
  • first 6-12 months

- CHRONIC ANKLE INSTABILITY (functional instability, joint laxity, decreased physical activity levels)

103
Q

When is SPECIAL TESTING for ankle ligament testing (ATFL and CFL) most effective?

A
  • ~5 days after (after swelling resolves)
104
Q

What cluster of tests/signs and symptoms increases the likelihood for determining POSITIVE LATERAL LIGAMENT SPRAIN?

A

Combo of:

  • TTP at ATFL
  • Lateral hematoma
  • +ve anterior drawer (~5 days after)

*100% sensitivity, 75% specificity

105
Q

What is one suggestion you can give an athlete after incurring a lateral ankle sprain, to prevent future sprains?

A
  • WEAR ankle brace (lace up more effective than semi-rigid)
106
Q

What are the RTP timeframes for lateral ankle sprains Grade 1, 2, 3a, 3b?

A 
1 = 7 days
2 = 15 days
3a = 30 days
3b = 55 days

*days double with increasing severity

107
Q

What is a Lisfranc injury?

A
  • sprain or rupture of lisfranc ligament with or without fracture
  • Lisfranc ligaments = Y-shaped PLANTAR ligament that goes from medial cuneiform to base of 2nd and 3rd metatarsals; DORSAL ligament that goes from medial cuneiform to base of 2nd MT; INTEROSSEUS ligament (between medial cuneiform and 2nd MT)
108
Q

What bone is the “keystone” of the transverse arch?

A
  • SECOND METATARSAL
109
Q

What are the MOIs for a LisFranc injury?

A
  • AXIAL LOADING and TWISTING over PLANTARFLEXED FOOT

- SEVERE HYPERPLANTARFLEXION (i.e., falling backward with foot caught in stirrup)

110
Q

What is “Fleck Sign”?

A
  • avulsion fracture at the base of the 2nd MT (Lisfranc injury)
111
Q

What are the signs and symptoms of a Lisfranc injury?

A
  • diffuse mid foot pain, swelling
  • plantar ecchymosis
  • reported PAIN with walking down stairs
  • TTP over dorsal aspect of TMT joints
  • pain with PASSIVE motion at midfoot
  • “GAP” sign = separation b/t 1st and 2nd toes (maybe)
112
Q

How are “Lower Energy” Lisfranc injuries DIAGNOSED?

A
  • combo of clinical exam AND
  • weight bearing RADIOGRAPHS

*Lower energy injuries = typically seen in athletics

113
Q

What are the stages of LOWER ENERGY Lisfranc injuries?

A
  • Stage 1 = ligament sprain, <2 mm diastasis
  • Stage 2 = ligament rupture, 2-5 mm diastasis
  • Stage 3= ligament rupture, >5 mm diastasis, collapse of medial arch
  • surgical stabilization recommended with 2 and 3
  • UNSTABLE injuries need surgical stabilization otherwise POOR outcomes (persistent pain and disability)
114
Q

What is a SPECIAL TEST to utilize to allow progression to GAIT out of the boot after LISFRANC INJURY?

A
  • ABDUCTION STRESS TESTING = stabilize calcaneus, grab forefoot, PRONATE and ABDUCT
  • if pain = +VE
  • if no pain = -VE and can begin walking (~6-8 weeks after injury)
115
Q

What SPECIAL TEST is used to allow return to INLINE athletic activities? Return to cutting/pivoting, uneven surface running?

A
  • PAIN-FREE ambulation down several flights of STAIRS
  • PAIN-FREE single leg HOP test x30 sec

*should expect RTP of >6 months for grade 2 and 3

116
Q

What is the HALLMARK PRESENTATION of PLANTAR FACIITIS?

A
  • PAIN with weight bearing (especially: in morning, WB after prolonged inactivity, or prolonged WB)
117
Q

What are some common clinical findings in those with PLANTAR FACIITIS?

A
  • TTP at proximal insertion
  • restricted dorsiflexion, hamstring flexibility
  • LLD has been observed in some
  • +ve WINDLASS test
  • Foot Posture Index (low score = supinated; high score = pronated)
118
Q

What are some recommended treatment interventions for PLANTAR FACIITIS per JOSPT CPGs?

A
  • TAPING (at gastroc of P. Fascia, OR to control pronation)
  • ORTHOTICS (pre-fab or custom)
  • NIGHT SPLINTS (for those with pain in the morning, 1-3 months timeframe)
  • PHONOPHORIESIS (ketoprofen for pain relief)
  • FOOTWEAR MODIFICATIONS (rocker bottom shoes, , shoe rotation through week with standing jobs)
119
Q

What is the difference between ACUTE LOWER EXTREMITY COMPARTMENT SYNDROME and CHRONIC EXERTIONAL COMPARTMENT SYNDROME?

A
  • ACUTE = emergent situation; fluid accumulation increases compartmental pressure = restricts vascular perfusion; can lead to tissue HYPOXIA and NECROSIS (if unrecognized and untreated)
  • CHRONIC = believed to be due to increased compartment fluid volumes driving increased pressure; exertion based; gradual onset; bilateral in 82% of cases
120
Q

What is CHRONIC EXERTIONAL COMPARTMENT SYNDROME a result of ?

A
  • dramatic CHANGE in training workload (longer or more intense bouts)
121
Q

What are the symptoms of CHRONIC EXERTIONAL COMPARTMENT SYNDROME ?

A
  • LOWER LEG PAIN - progressive

- PARESTHESIA or WEAKNESS (hallmark = when discontinuing activity)

122
Q

How is CHRONIC EXERTIONAL COMPARTMENT SYNDROME diagnosed?

A
  • clinical SIGNS and SYMPTOMS
  • NEEDLE MANOMETRY
    Pre-exercise pressure >15 mmHg
    Immediately post exercise >30 mmHg
    5 min post exercise >20 mmHg
123
Q

What are some TREATMENTS for CHRONIC EXERTIONAL COMPARTMENT SYNDROME?

A
  • ACTIVITY MODIFICATION/REST EDUCATION
  • transition to FOREFOOT STRIKE (for runners)
  • BOTOX (effective in anterior and lateral compartments)

*surgical COMPARTMENT RELEASE if conservative tx fails

124
Q

What is the difference in NON-INSERTIONAL and INSERTIONAL ACHILLIES TENDINOPATHY?

A
  • Non-insertional = ~6 cm from insertion; more common in older, less active, overweight
  • Insertional = more in active population
125
Q

What are 2 theorized sources of pain in ACHILLES TENDINOPATHY?

A
  • Neo-vascularization with accompanying neo-nerves

- Elevated GLUTAMATE levels in symptomatic tendon (though they remain elevated after pain is resolved)

126
Q

Who is ACHILLES TENDINOPATHY most common in?

A
  • men
  • 30-55 years
  • runners
127
Q

What is a cardinal sign of ACHILLES TENDINOPATHY? What are the most ACCURATE tests for diagnosing it?

A
  • PAIN and STIFFNESS after prolonged periods of rest (in acute stages)
  • LOCATION of pain, and pain with PALPATION
128
Q

What does current evidence suggest regarding EXERCISE and TREATMENT of ACHILLES TENDINOPATHY?

A
  • LOAD matters most when treating TENDINOPATHIES (versus type of contraction)
  • though ECCENTRIC exercises has the most evidence, (isometric, tendon neuroplastic training, heavy slow resistance training)
129
Q

What is the “KISSING PHENOMENON” as it relates to rehabbing ACHILLES TENDINOPATHY?

A
  • IRRITATION of the tendon just proximal to insertion when performing eccentric heel raises on step when stretched to end range
  • with INSERTIONAL TENDINOPATHY = perform on flat surface to avoid this
130
Q

What factors increase the likelihood of ACHILLES TENDON RUPTURE/TEAR?

A
  • WATERSHED area (3-6 cm proximal to distal insertion); perfusion is also affected when this area is stretched
  • COLLAGEN DEGENERATION = decreased strength in tendon with age
131
Q

What are 2 MOIs for PERONEAL TENDON INJURIES?

A
  • ANKLE INVERSION
  • EXTREME ANKLE DF and EVERSION coupled with strong PERONEAL contraction = can tear PERONEAL RETINACULUM resulting in dislocation, tear, or instability of peroneal tendons
132
Q

What test may detect TENDON SUBLUXATION in PERONEAL TENDON INJURIES?

A
  • RESISTED DORSIFLEXION with SUBTALAR EVERSION
133
Q

What is the “Peek-a-boo” sign?

A
  • For observing subtle PES CAVUS deformity

- Visualization of medial aspect of calcaneus while observing patient from anterior view

134
Q

What does the Coleman Block Test assess?

A
  • stand with LATERAL ASPECT of foot on BLOCK
  • determines if PES CAVUS is coming from HINDFOOT (great toe doesn’t touch floor) OR FOREFOOT (great toe touches the floor)
135
Q

What is HAGLUND’S DEFORMITY?

A

Bony prominence/enlargement at posterior calcaneus due to REPEATED FRICTION

136
Q

What sports is RETROCALCANEAL BURSITIS and HAGLUND’S DEFORMITY common in? Why does it occur in each?

A
  • Figure skaters (skates stiff and/or poor fitting)

- Runners (tight shoes, overtraining, altered biomechanics)

137
Q

What sports is RETROCALCANEAL BURSITIS and HAGLUND’S DEFORMITY common in? Why does it occur in each?

A
  • Figure skaters (skates stiff and/or poor fitting)

- Runners (tight shoes, overtraining, altered biomechanics)

138
Q

What is HAGLUND’S DEFORMITY?

A

Bony prominence/enlargement at posterior calcaneus due to REPEATED FRICTION

139
Q

How is SEVER’S DISEASE caused?

A
  • repeated TRACTION and SHEAR on CALCANEAL growth plate (excessive running, jumping)
140
Q

What are some possible RISK FACTORS for SEVER’S DISEASE?

A
  • increasing volume and/or intensity of training

- pes cavus or planus (may affect loading and/or lead to stiffness of achilles = increasing stress on insertion)

Sport Prep (10 decks)

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