lower leg Flashcards
Fx screening method
Tuning fork
-methodology: provocation of pain, sound conduction
128Hz
vibratory irritation at damaged periosteum
Fx screening clinical value
Tuning fork
-sensitivity is questionable
-may not identify fx with callus
-better for transverse fxs
-less accurate for stress fxs
Ottawa ankle rules
An ankle xray is only required if there’s pain in the malleolar zone AND these findings:
1. bone tenderness at lateral malleolus
2. bone tenderness at medial malleolus
3. inability to WB immediately for 4 steps
A foot xray is only required if there is pain in midfoot AND any of these findings:
1. Bone tenderness at base of 5th met
2. bone tenderness at navicular
3. inability to WB immediately for 4 steps
Traumatic fxs: distal tibia/fibula (MOI, types)
MOI: axial/rotational loading
Types:
-Unimalleolar fx: medial or lateral
-Bimalleolar fx: both
-Trimalleolar fx: both and posterior rim of tibia
-tibia and fibula shaft fx
-comminuted fx distal tibia
-intra-articular fxs
Traumatic fxs: Hindfoot
Calcaneus:
-MOI: fall from height
-intra vs extra-articular
Talus
-MOI: forced ankle DF
-Most intra-articular
-involving head neck or body
Traumatic fxs: Midfoot and forefoot
Navicular
-dorsal avulsion at deltoid attachment
-tuberosity fxs
-body fxs
-stress fxs: common insidious onset in WB athlete
Metatarsal
-MOI: direct trauma
-1st met
-2-4: spiral common
-5th: avulsion, stress fx
Phalangeal
-MOI: stubbing and direct trauma
Pediatric physeal ankle fxs surgery
-reduction of displaced fx (closed vs open)
-fixation vs no fixation (ORIF common for types 3 and 4)
Pediatric physeal ankle fxs prognosis
-worse if >1week prior to reduction
-larger gap
-gap >/= 3mm for types 1-2
-younger patients (more growth to come)
-higher risk of physis arrest in types 3-5 (f/u assess 2 yrs s/p fx)
Pediatric physeal ankle fxs types 1-5
1-2: typically casted 4-6 weeks following reduction
3-4: long leg NWB cast 1-4wks,
boot from 5-8wks (NWB first 2 wks, may remove for ROM)
If ORIF w/ type 3, common hardware removed once healed
5: recognized early-mx with removal of physis area f/b fat graft
Abnorms: Talipes Equinovarus (clubfoot)
-BILAT
-M>F
-PF heel, inversion STJ/varus rearfoot, met ADD/ varus forefoot
Rearfoot varus/valgus
varus: inversion of calc w/ subtalar in neutral (limit pron)
valgus: eversion calc w/ subtalar in neutral (excess pron, limit supin)
Forefoot varus/valgus
Varus: inversion forefoot on hindfoot w/ subtalar in neutral
Valgus: eversion of forefoot on hindfoot w/ subtalar in neutral
Pes planus(flat foot)/ cavus
Planus:
-Rigid/congenital: calc in varus, midtarsal region in pron, talus medial and downward, navicular dorsal and lateral on talus
-Aqcuired/flexible: like rigid, but foot mobile
Cavus: longitudinal arches accentuated
Hallux valgus (bunion)
-medial deviation of 1st met and lateral dev of great toe
-gait: collapse of medial arch, navicular drop, position of pronation during push-off= less rigid foot
Hallux rigidus
-arthropathy of great toe- pain, swelling, abnorm bone growth at dorsal 1st MTP
hx: arthropathy, trauma/injury, repetitive great toe ext
sxs: insidious onset, progressive, 1st MTP pain especially w/ walking uphill, stairs, terminal stance
exam: limited toe ext ROM, bony/hard PROM, gait devs, abrasion to skin, swelling, palpable osteophyte/tenderness
Ankle sprains (Inversion)
COMMON
ATFL involved a lot
Differential: avulsion fx 5th met styloid process, osteochondral lesion, malleolar fx
Ankle sprains inversion hx
30’s
running injury
athletes 5x likely to sustain lateral ankle sprain after initial sprain occurred
MOI: forced ankle inversion
Inversion sprain sxs
lateral ankle pain
lateral ankle swell/warmth/red
pain w/ activities that supinate foot
Inversion sprain exam
antalgic gait
increased figure 8 measure
local warm/tender (ATFL)
pain w/ inversion
+anterior drawer
+medial talar tilt
+reverse anterolateral drawer
Medial ankle sprain hx and sxs
-involves deltoid lig
hx: MOI forced ankle eversion
sx: medial ankle pain, medial swell/warm/red, pain with pronated positions
Medial ankle sprain exam
antalgic gait
increased figure 8
warm/tender area distal to medial malleolus
pain with pronation/eversion ROM
+lateral talar tilt stress test
Syndesmotic sprain MOI
“high ankle sprain”
concern chronic instability/degen arthropathy
MOI: forced DF, forced eversion of talus, forced ER of talus
Syndesmotic sprain sxs
pain distal lower leg
aggravated w/ stair descent/walking uphill/squat
Syndesmotic sprain exam
-early heel off in stance
-swell/tender A. tibiofib joint
-pain end range DF ROM
+fibular translation
+external rotation
+syndesmosis squeeze
CAI hx
recurrent inversion sprains
fibular muscle weakness
impaired proprio
CAI sxs
asymp. between sprains
feels of ankle giving way
ankle weakness
difficult/inability to run (worse on uneven)
CAI exam
diminished proprioceptive func of ankle
Dx/classify CAI
use Cumberland ankle instability tool or identification of functional ankle instability
also func performance tests
Anterior ankle impingement hx
-soft tissue or bony spur formation at anterior TC joint
recurrent/high trauma ankle sprains
AAI sxs
anterior ankle pain
anterior ankle swell/warm/red
pain with activities that put foot in DF
AAI exam
antalgic gait/ early heel off
tender/palpable mass anterior tibiotalar joint
pain/limit with end range DF ROM
+forced DF test
Impingement CPR (6)
5/6:
AL ankle joint tender
AL ankle joint swelling
Pain w/ forced DF
Pain w/ single leg squat
Pain with activities
Absence of ankle instability
*use with caution, not great
FL/B tendinopathy hx
repeated inversion injuries
anatomic abnorms/anomalies
FL/B sxs
pain posterior to lateral malleolus
sublux of fibularis tendons
FL/B tendinopathy exam
swell/bruise lateral ankle
pain with AROM< RT ankle eversion
pain w/ end range inversion/supin
tender fibularis longus/brevis tendons
Tib P tendinopathy hx
insidious, progressive, unilateral
concomitant deltoid lig injury
playing sports that require quick directional change
Tib P tendinopathy sxs
pain near area of insertion at navicular
pain prox to medial malleolus
Tib P tendinopathy exam
-foot posture: pronated foot/pes planus
-navicular drop in standing (1cm)
-tender/swell navicular or prox to medial malleolus
-pain with resisted inversion and PF
-painful eversion/ DF ROM
Achilles tendinopathy hx
MOI: intense eccentric loading on triceps surae (gastroc/soleus complex)
running injuries!
Achilles tendinopathy sxs
pain near insertion of achilles tendon
morning stiffness
Achilles tendinopathy exam
-tenderness/swelling/hypertrophy/ palpable defect
-pain w/ DF ROM
-Pain w/ AROM< resisted PF
Achilles tendon tear/rupture hx
MOI: sudden push off w/ extended knee, sudden forced DF
-Sudden/ acute onset known mechanism, “pop”, difficulty walking/WB
-hx of Achilles tendinopathy
-middle aged adult
achilles tendon tear/rupture
sx: pain near insertion of achilles tendon
exam: tender/swell/hypertrophy/ palp defect of tendon/posterior calf
-pain DF ROM
-weak/absent active/resisted PF
+thompson test (rupture)
Plantar faciitis hx, sx
high lifetime prevalence
hx: rfs- limited DF ROM, high BMI non-athletic populations
sxs: plantar medial heel pain (worse w/ first few steps following inactivity and with prolonged WB activity
-pain w/ terminal stance
Fasciitis exam
-early heel off in stance
-guarding triceps surae
-swell/tender origin of plantar fascia (potentially heel spur)
-pain w/ passive DF of ankle and toes (windlass)
Dx plantar fasciitis
-plantar medial heel pain, noticable after inactivity/prolonged WB
-heel pain from increase in WB activity
-pain w. palp of prox insertion of plantar fascia
-+windlass
-negative tarsal tunnel tests
-limit A/PROM TC joint DF ROM
-abnormal foot posture index score
-high BMI, nonathletic
metatarsalgia hx
where is pain also
pain in distal forefoot, area of met heads
hx: health conditions that increase stress on met head
metatarsalgia sxs
aggravated w/ prolonged WB activities, mid and terminal stance phases of gait
metatarsalgia exam
-findings for concomitant health conditions
-antalgic gait/ diminished push off
-observable calluses on plantar foot
-tender plantar met heads
Interdigital neuroma hx
thickening of soft tissue surrounding interdigital nerve
hx: insidious vs sudden onset (DF injury of toes)
IN sxs
pain in area of met heads and web space
IN exam
tenderness
+foot squeeze test
TTS what is it
Peripheral nerve entrap of posterior tibial nerve
characterized as compression of soft tissue structures that pass deep to flexor retinaculum, posterior and distal to medial malleolus of tibia
TTS sxs
loss plantar sensation
pain/paresthesia at plantar foot
increasing intensity of sxs w/ DF activities
TTS rfs
obesity
venous insufficiency
space occupying lesions
trauma
peripheral vascular disease
DM
tight shoes/casts
foot deformities
TTS Paucity of Lit
epidemiology of heel pain of neurologic etiology
*not a lot of research to show why, LACK OF LIT
TTS exam
antalgic gait (alters to avoid DF)
limit/pain squat (avoid DF)
signs of invertor tendinopathy
diminished plantar sensation
weakness of intrinsics
limited ROM, pain DF eversion
+Tinel sign
LLTT w/ posterior tib bias
TTS
rfs
what to do
aftercare
underlying cause not identified
>among females
~47 yos
Tarsal tunnel decompression (release) -flexor retinaculum incised, eliminates compressive force on deep neurovascular structures
post op careL
limits ankle ROM, splint 7-14days
mod locomotion w/ ADs
progress to WBAT after sutures removed
PT
