Lower Leg & Ankle Complex Flashcards
1
Q
Lateral (Inversion) Ankle Sprain
Description
A
- Tearing of the ligaments on the outside (lateral) part of the ankle
- Very common injury
- May involve one or more ligaments on the lateral ankle
- Ligaments of lateral ankle: ATFL, CFL, PTFL
2
Q
Lateral (Inversion) Ankle Sprain:
Etiology
8
A
- Involves traumatic incident
- Common MOI is PF + inversion
- Jumping & landing on uneven surface (ie basketball player landing on another foot)
- Running on uneven surfaces
- Increased risk of injury in individuals w/ weak peroneal mm (everters - NOT supporting you in that direction) & ankle instability likely d/t repeated strains
- Order of injury during PF + inversion = ATFL > CL > PTFL
Inversion + neutral = CFL
Inversion + DF = PTFL
3
Q
Lateral (Inversion) Ankle Sprain:
S/S
(8)
A
- Acute onset
- Swelling/ inflammation
- May present with warmth on lateral ankle
- May present with bruising
- Lateral ankle pain - worse w/ inversion & WB (helps to stabilize a weight bearing joint)
- Tenderness on palpation
- May present with instability
- Decrease proprioception
4
Q
The West Point Ankle Sprain Grading System
A
Criteria: Grade 1
1. Location of tenderness: ATFL
2. Edema & ecchymosis: Slight local
3. Weight-bearing ability: FWB or PWB
4. Ligament damage: Stretched
5. Instaility: None
Criteria: Grade 2
1. Location of tenderness: ATFL & CFL
2. Edema & ecchymosis: Moderate local
3. Weight-bearing ability: Difficult w/o crutches
4. Ligament damage: Partial tear
5. Instaility: Slight
Criteria: Grade 3
1. Location of tenderness: ATFL, CFL & PTFL
2. Edema & ecchymosis: Significant diffuse
3. Weight-bearing ability: Impossible w/o significant pain
4. Ligament damage: Complete tear
5. Instaility: Definite
5
Q
Lateral (Inversion) Ankle Sprain:
Special Test & Other
2 + 3
A
- Anterior Drawer (of Ankle)
- Talar Tilt
Other:
1. Ankle Lunge Test (knee-to-wall)
2. Proprioception testing
3. Strength testing (ie heel raises)
6
Q
Medial (Enversion) Ankle Sprain
(4)
A
- Tearing of the ligaments on the inside (medial) part of the ankle
-
Much less common than the lateral ankle sprain d/t the fibula blocking excess eversion & the strength of the medial ligaments
Fibular extends further fown the leg compared to medial malleolus - Dut to strength of deltiod ligament, medial ankle sprains are typically associated w/ an avulsion fracture
- Ligaments of medial ankle: anterior tibiotalar, posterior tibiotalar, tibiocalcaneal, tibionavicular
7
Q
Medial (Enversion) Ankle Sprain:
Etiology
(4)
A
- Involves traumatic incident
- Involves everison of the ankle
- Jumping & landing on uneven surface
- Running & cutting
8
Q
Medial (Enversion) Ankle Sprain:
S/S
(8)
A
- Acute onset
- Swelling/ inflammation
- May present with warmth on medial ankle
- May present with bruising
- Medial ankle pain - worse w/ eversion & WB
- Tenderness on palpation
- May present with antalgic gait
- Decrease proprioception
9
Q
Medial (Enversion) Ankle Sprain:
Special Test
(3)
A
- Anterior Drawer Test (of the ankle)
- Talar Tilt (Eversion Stress Test)
- External Rotation Stress Test
Other:
- Lunge Test (knee-to-wall)
- Proprioception testing
- Strength testing (ie heel raises)
10
Q
Medial (Enversion) Ankle Sprain:
Interventions
A
PT Management:
- Manage pain
- Manage swelling
- Bracing/taping
- Crutches if necessary
- Strengthening
- Proprioception
- Restore ROM
- Cross friction massage as tolerated
11
Q
High Ankle Sprain (Syndesmotic Ankle Sprain)
(5)
A
Less common but more diabling
- Tearing of the syndesmotic ligaments which connect the tibia & fibula
- Described as high ankle sprain d/t the location of the sprain being above the ankle (talocrural) joint
- Rarely occurs in isolation. Typically associated w/ deltoid ligament injuries or fractures of the fibula or medial malleolus
- May involve one or more ligaments of the “high ankle” (4)
- Ligaments of the high ankle: AITFL, PITFL, Interosseous membrane
12
Q
High Ankle Sprain (Syndesmotic Ankle Sprain):
Etiology
(3)
A
- Involves traumatic incident
- External rotation of the foot - FORCED hyper ER
- Hyper-dorsiflexion - falling from a high height & land on their feet
13
Q
High Ankle Sprain (Syndesmotic Ankle Sprain):
S/S
(8)
A
- Acute onset
- Swelling/inflammation
- May present with warmth on anterior ankle
-
Anterior ankle pain
Worse with ER of the foot & weight bearing - Tenderness on palpation over syndesmosis & interosseous membrae
- May present with antalgic gait
- Decrease proprioception
- May present with widening of mortis on imaging
14
Q
High Ankle Sprain (Syndesmotic Ankle Sprain):
Special & Other Tests
A
- External Rotation Stress Test
- Sqeeze Test
Other:
1. Ankle Lunge Test (knee-to-wall)
2. Proprioception testing
3. Strength Testing
15
Q
High Ankle Sprain (Syndesmotic Ankle Sprain):
Intervention
A
PT Management:
- Manage pain
- Manage swelling
- Bracing/taping
- Crutches if necessary
- Strengthening
- Proprioception
- Restore ROM
- Cross friction massage as tolerated
16
Q
Fractures:
Ottawa Ankle Rules
(3) Description & Specifcs
A
- Guideline to help clinicians decide whether or not a patient should be referred for radiographic imaging
- In the past, an excess amount of radiographs were ordered for foot/ankle injuries which were not required & resulted in negative findings
- Radiographs can be costly, time consuming, & potentially harmful to pt
- Bony tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus
- Bony tenderness along the distal 6 cm of posterior edge of tibia/tip of medial malleolus
- Bony tenderness at the base of 5th metatarsal
- Bony tenderness at the navicular
- Inability to bear weight both immediately after injury & for steps during inital evaluation
17
Q
MOI - Avulsion #
(2)
A
- Medial Ankle Sprain
- Peroneal brevis tendon pullong base of 5th MT
Can contact eccentrically so hard that it pulls off a piece of bone
18
Q
Achilles Tendinosis
Description & Classification
A
Degenerative changes to the Achilles tendon
Chronic Achilles tendinopathy may lead to thickening of the tendon
Classification:
Insertional: < 2cm from calacaneal insertion
Midsubstance: 2-6 cm from calcaneal insertion
19
Q
Achilles Tendinosis:
Etiology
Extrinsic & Intrinsic
A
Extrinsic Factors:
Sudden & drastic change in training regime
- Training time
- Training Frequency
- Distance
- Intensity
- Surface
- Footwear - MAIN RISK (ie suddenly switching from high heeled shoe > flat shoe)
Intrinsic Factors:
- Age
- Reduced DF (tight RF mm = excessive strain)
- Foot pronation (static or dynamic)
- Weight gain
20
Q
Achilles Tendinosis:
S/S
(10)
A
- Insidious onset
- Morning stiffness
- Decreased ankle DF
- Decreased strength in ankle PF (attachment of PF mm)
- Pain
Increased w/ active/resisted PF, passive DF, or WB
Decrease pain w/ walking about or applying heat - Tenderness on palpation
- Antalgic gait
- Thickening of Achilles tendon
- May present with retrocalcaneal exostosis
Also known as a “pump bump”, Haglund deformity, or Achilles heel bone spur
Often seen in females when it was fashionable to wear pumps
Often leads to retrocalcaneal bursitis - May present with crepitus (if paratenonitis is also present)
Inflammation of the tendon itself
21
Q
Achilles Tendinosis:
Intervention
(8)
A
- Avoid aggravating activities
- Eccentric exercsies for PF (ie heel drops)
- Increasing shoe height & progressively decreasig heel height
INC depth of shoe = taking load (stretch) off tendon
UNLOADing & then progressively loading it back - Stretching of PS - temporary analgesic affect BUT if it is aggravating it - stop - could be sensitizing the tissue
- Manage pain
- Taping
- Night splint
- Manage inflammation if paratenonitis or retrocalcaneal bursitis also present
Any inflammation in the area > manage it
22
Q
Achilles Rupture
Description & Epi
A
A full tear (grade III strain) of the Achilles tendon
- Typically occurs ~2-6 cm proximal to calcaneal insertion
Epi:
- M>F
- Athletes in their 30s & 40s
23
Q
Achilles Rupture:
Etiology
(4)
A
- Direct trauma (ie direct blow or cut)
- Rapid or forceful concentric contraction (ie jumping)
- Eccentric overload (ie landing from a jump)
- Corticosteriod use - weakens connective tissue
24
Q
Achilles Rupture:
S/S
(8)
A
- Patient may report audible snap or tear at time of rupture
- Swelling
- May present with warmth surrounding tendon
- May present with bruising
- Obvious limp - use of PF are not connected = no engagement
- May present with palpable gap in tendon
- Gross decreased strength in PF (secondary PF may provide some PF in supine but not strong enough in standing)
- May present with pain
25
Achilles Rupture:
Special Test
| 1
Thompson's Test
Squeeze calf to see if foot PF
Good confirmation test
26
Achilles Rupture:
Interventions
PT Management:
- Cast immobilization in maximal PF for **4 weeks**, followed by **4 weeks** of immobilization in gradually reduced amounts of PF
- Crutches (NWB)
- Progressive ROM & strengthening exercises following immobilization
- Proprioception exercies
**HIGHER risk of re-rupturing**
Surgical Management:
- Rupture repair (suturing of tendon)
- Immobilization post-op same as conservative approach. Strength & ROM may be difficult to regain after rupture repair
**HIGHER risk of complications** (as w/ any invasive Sx - infection)
27
Sever's Disease
| Description & Epi & Etiology
A traction apophysitis at the calcaneal insertion of the Achilles tendon
Epi:
- Common overuse injury in growing children
- Typically occurs in ages **7-10** (d/t calcaneus not being developed yet)
Etiology:
- Repeated tension on growth plate of calcaneus
- Growth-spurt - tib/fib faster than mm are lengthening
- Over-pronation
- Increase incidence in sports that involve running or jumping (espeically on hard surfaces)
28
Sever's Disease:
S/S
| (4)
1. Heel pain (posterior-plantar side) - where achilles is attaching
Worse w/ walking, running, jumping ~ when using / stretching the calf mm
2. May present with antalgic gait
3. Pain w/ **pressure** over **medial & lateral calcaneus** in the area of the growth plate
4. May present with DEC passive DF
29
Sever's Disease:
Intervention
1. Manage pain
2. Decrease parameters of aggravating activity (ie freq, intensity, duration)
Do not want to suggest STOPPING the activity completely - but modify activity to DEC pain
3. Foot orthotics
4. Stretching - INC mm length - TRUE lengthening = 5 mins or longer
5. Heel lift = DEC amount of stretch
30
Shin Splints & Classifications
The term "shin splints" has many different meanings.
It is commonly described as a non-specific umbrella term to describe pain along the **tibia**
- It is sometimes meant to refer to pain along the **medial border of tibia** & is synonymous w/ **medial tibial stress syndrome (MTSS)**
Classifications:
1. Periositis
2. Stress fracture - micro
3. Compartment Syndrome - fascial compartment w/ too much pressure
31
Periostitis
Inflammation of the **periosteum** (outer bone), a layer of connective tissue surrounding the bone
- Thought to be d/t **chronic pulling (traction)** of the periosteym by the **mm connecting to the periosteum** w/ repeated activity
**ANTERIOR Shin Splints** (anterior tibial traction periostitis)
- Over use of the **tibialis anterior**, extensor digitorum longus, & extensor hallicus longus
- Pain over the proximal 2/3 of anterolateral aspect of tibia
- Pain w/ resisted DF & passive PF (Pain w/ anything that is contracting/stretching the TIB ANT)
*Last 2 pt - usually not enough load to provoke symptoms*
**POSTERIOR Shin Splints** (medial tibial traction periostitis)
- Overuse of **tibial posterior mm**
- Pain over the distal 1/3 of posteromedial aspect of tibia
Palpate: medial edge of tibia > go b/t calf & tibia > deep groove is where the TIB POST is = tender
- Pain w/ active supination (contracting) & w/ passive DF + eversion (stretching)
**MOST COMMON**
32
What is the most common type of shin splint?
Posterior Shin Splint (medial tibial traction periostitis)
33
Periostitis: Etiology
| Extrinsic + Intrinsic Factors
Extrinisc Factors:
**Sudden or drastic change in training regime**
- Training time
- Training frequency
- Distance
- Intensity
- Surface
- Footwear
**BIGGEST cause - more evidence**
Instrinsic Factors:
- Over-pronation - TIB POST tendon is going on stretch (wraps under surface of medial side) > eccentrically loading it
- Muscle dysfunction (tib post vs anterior)
- Fatige
- Decreased flexibility = INC traction on area
34
Periostitis: S/S
| (3)
1. Gradual onset
2. Diffuse pain
Increases w/ activity (until mm is warmed up)
Decreases or dissapears w/ warming up & at rest
3. Diffuse tenderness on palpation
TEMPORARY period after they stop running - starts to INC & then DEC again
35
Periostitis: Interventions
1. Avoidance of aggravating activities (take a break from running)
2. Manage inflammation
3. Manage pain
4. Taping - approximate mm that is pulling towards the bone can be effective
Tib post - rotate mm (calf) to MEDIAL side - mm closer to their insertion on the tibia = less pulling
5. Orthotics
POST = excessive pronation > orthotics would prevent foot from dropping > supporting medial longitudinal arch
6. Stretching (when not aggravated) & soft tissue mobilization
7. Strengthening (graduated w/ an eccentric focus)
8. **Walk-run program** - progressively loading them ack up to get back to their activities
9. Address alignment & biomechanical issues
36
Stress Fracture
Overuse injury to the bone typically from repetitive loading leading to microdamage
37
Stress Fracture: Etiology
| Extrinsic & Intrinsic Factors
Extrinsic:
**Sudden or drastic changes in training regime**
- Training frequency
- Training time
- Intensity
- Distance
- Surface: **MOST common** more forgiving (grass) > hard surface
- Footwear
Intrinsic Factors:
- Cavus foot: high arch = less shock absorption = more stress on structures & tibia is the one to fail
- Overportnation - not getting shock absorption (going right into pronation)
- Overall limb & foot alignment - may lead to overuse & excess loading
*Had this alignment all thier life - really is's a chang ein load that is greater than capacity*
- LLD - overloading short limb more
38
Stress Fracture: S/S
| (3)
1. Gradual onset
2. **FOCAL** pain
Pain present w/ activity & rest
Pain remains constant or slightly increases with activity - same pain during duration
Worse at night
Worse w/ impact activities - everytime they hit the ground = pain
3. Tenderness on palpation over bone
39
Stress Fracture: Special Test
| 1
Stress Fracture Test (tuning fork vibration)
- Make fork vibrate - touch the bone & this irritates the places w/ hairline #
Another test: use ULTRASOUND & crank it up - go over area w/ hairline fracture > pt will say it is painful - soundwaves are getting into the cracks in the bone & irritating it
40
Stress Fracture: Intervention
1. Inital period of rest
2. Avoidance of aggravating activities
3. Crutches if required
4. Gradual progressive loading (walk-run program)
5. Walk-run program
**Stress # will NOT show up on an x-ray early on - pt would require a bone scan**
**WOLF'S LAW** - a bone in a healthy person will adapt to its imposed demand.
- As we start adding load, it will adapt to that demand
41
Compartment Syndrome
- Increased pressure within a fascial compartment of the lower leg which contrains mm, nerves, & blood vessels
- May result in DEC BF ("choke them out") > DEC tissue perfusion (INC fatigue) > INC ischemia > pain & potentially permanent damage (ischemic cell death)
- The **anterior** & the **deep posterior** compartments are more commonly involved in comparment syndrome
- Chronic **Exertional** Compartment Syndrome is increased pressure w/in fascial compartment of the lower leg during activity
MM pump > more blood > INC swelling > INC pressure - all contained in a tight compartment
42
What are the most commonly involved compartments in compartment syndrome?
1. Anterior
&
2. Deep posterior
43
Different Compartment Syndromes
| Name, MM, Nerves, & Arteries/Veins
Compartment: **ANTERIOR**
Muscles:
- Extensor hallucis longus
- Extensor digitorum communis
- Tibialis anterior
- Peroneous Tertius
Nerves: Deep peroneal nerve (innervates the above mm)
- Cutaneous innervation: Webbing between the 1st & 2nd digit - lose/altered sensation
Arteries/Veins: Anterior tibial artery
S/S: Foot drop - nerve in DF are affected & nothing opposing PF
Compartment: **LATERAL**
Muscles: EVERTORS
- Peroneous brevis
- Peroneous longus
Nerves: Superficial peroneal nerve
-Cutaneous innvervation: Dorsum of the foot except for the webbing between 1st & 2nd digits
Arteries/Veins: Peroneal artery
S/S: May look like inverted foot b/c mm are not being opposed by the everters
Compartment: **POSERIOR SUPERFICIAL**
Muscles:
- Gastroc
- Soleus
- Plantaris
Nerves: Sural nerve (purely sensory - branch of tibial n.)
- Cutaneous innervation: Posterior lateral aspect of leg & the lateral foot & 5th digit (pinky)
Arteries/Veins:
- Posterior tibial artery
- Popliteal artery
- Peroneal artery
- Sural arteries
Compartment: **POSTERIOR DEEP**
Muscles:
- Tibialis posterior
- Flexor hallicus longus
- Flexor digitorum longus
- Popliteus
Nerves: Tibial nerve
- Cutaneous innervation: plantar aspect of the foot
Arteries/Veins:
- Posterior tibial artery
- Peroneal artery
**BASED on the compartment syndrome S/S, you will know how to differentiate what compartment is affected b/c you know what nerve is affected - sensory & motor component**
44
Compartment Syndrome: S/S
| (7)
1. Gradual onset
2. Diffuse pain
Pain described as **Severe cramping**
*May see also w/ IC (NO neural component) - difference: IC is affecting the blood vessel directly - PVD impeding BF II ECP is from pressure from outside - tightening up area (NEURAL component)*
Increased with activity
Decreased or dissapears w/ rest (significant decrease w/in several minutes)
3. Severe cramping
4. **Tightness sensation**
5. May present w/ motor weakness
6. May present with altered or absent sensation
*5-6 is if nerves are affected*
7. May present with vascular S/S (ie red, hot, glossy skin)
45
Compartment Syndrome: Special Tests
| (4)
1. Compartment Pressure (gauge) test
Needle w/ guage before activity & then reassess immediately post-activity (meausre pre-post)
2. Pulse palation
3. MMT
Quick strength test pre-post exertion - compare
4. Sensory testing
Checking skin sensation pre/post (see if it is altered)
46
Compartment Syndrome:
Intervention
PT Management:
- Rest
- Soft tissue mobilization
Surgical Management:
- Interosseous Membrane Release (fasciotomy) - cut & open up compartment
47
Shin Splint - DDx
| (4)
1. Compartment Syndrome
2. Perostitis
3. Stress Fracture
4. Tumor
| SEE CHART on page.232-233
48
Tarsal Tunnel Syndrome
Compression of the posterior tibial nerve through the tarsal tunnel
- **MOST common nerve entrapment at the ankle**
- The tarsal tunnel is created by the bone & flexor retinabulum
Tarsal Tunnel contians:
1. **T**ibial posterior tendon
2. Flexor **d**igitorum longus tendon
3. Posterior tibial **a**rtery & **v**ein
4. Tibial **n**erve
5. Flexor **h**allucis longus tendon
Superior > inferior
**tom, dick, & a very nervous harry*
49
Tarsal Tunnel Syndrome:
S/S
| (2 + 4)
Pain & paresthesia
- Burning, electrical shock nerve pain
- Plantar surfae of the foot (closer to heel)
- Increased w/ weight bearing activity
- Decreased w/ rest
May present with swelling in feet
- May further irritate TIBIAL nerve in tarsal tunnel
50
Tarsal Tunnel Syndrome:
| 1
Tinel's sign at the ankle
- Tap on the tunnel: located posterior to medial malleolus
