Lower leg - ankle / foot Flashcards
1
Q
Compartment Syndrome or Chronic Exertional Leg Syndrome can be divided into?
A
Anterior, lateral and posterior [superficial and deep]
2
Q
The anterior compartment of the lower leg. Muscles and presentation of compartment syndrome
A
- tibialis anterior, EHL, EDL, fibularis tertius.
- Presentation: dysesthesias over the dorsum of the foot (web space of great toe), foot drop, sensation of loss of ankle control
3
Q
The lateral compartment of the lower leg.
Muscles and presentation of compartment syndrome
A
- Fibularis brevis and longus
- Presentation: Weakness of foot eversion and or loss of sensation over the anterior lateral shin and dorsum of the foot
4
Q
The posterior compartment of the lower leg
Muscles and presentation of compartment syndrome
A
Superficial
- Gastrocnemius, Soleus, Plantaris
- Presentation: Weak plantarflexion
Deep posterior:
- Popliteus, Tibialis posterior, FHL, FDL
- Presentation: Weakness of the foot muscles and loss of abnormal sensation long the plantar aspect of the foot.
5
Q
The anterior compartment of the lower leg nerve supply
A
Deep fibular n.
6
Q
The lateral compartment of the lower leg nerve supply
A
Superficial fibular n.
7
Q
The superficial and deep posterior compartment of the lower leg’s nerve supply
A
Tibial n.
8
Q
Overall Clinical Presentation of Compartment syndrome
A
- pain at start of activity and resolves when activity stops.
- 22-28 months diagnosis
- foot drop (weak dorsiflexion)
- paraesthesia
- pain described as pressure, burning or cramp
- tenderness upon palpation of compartment
- muscle herniation or bulging
- later presentation = constant pain
9
Q
Physical examination of compartment syndrome and diagnositcs
A
- before & after exercise
- observe static and dynamic
- gait during walk and run
- any muscle herniations during these motions
- ROM active and passive
- palpation of compartment
Diagnostics: Intramuscular compartment pressure [IMCP]
10
Q
Management of Compartment syndrome
A
Acute: Surgical release
Chronic: Activity modification, rest/ice/NSAIDS, stretching, shoes/orthotics and botulinum toxin A
usually caught too late to release pressure
11
Q
MTSS (Shin Splints) – Medial Tibial Stress Syndrome
Clinical presentation
A
- Posteromedial border of tibia pain during exercise
- palpation reproduces pain (over 5cm)
- bony pain
- dynamic hyper pronation
- pitting oedema over max tender area
- no neurovascular changes
12
Q
Medial Tibial Stress Syndrome Risk Factors
A
female, weight, high navicular drop, previous run injury, high hip external rotation
13
Q
Medial Tibial Stress Syndrome
Paitent History
A
- Pain with exercise along distal 2/3, provoked during or after activity and reduced with rest.
- Cramping, burning pain over the posterior compartment.
= Either CECS alone or possible additional MTSS. - No cramping/burning but numbness, pins/needles in foot during exercise = Either CECS alone or possible additional MTSS.
14
Q
Medial Tibial Stress Syndrome
Physical Examination and
Imaging Diagnosis
A
Ve+ S&S during history
Recognised pain on palpation of posteromedial tib border (over 5cm)
MRI
15
Q
Medial Tibial Stress Syndrome
Managment
A
Conservative; RICE and NSAIDs , Activity modification, Orthotics and manual therapy ,
Mean recover 2-6 weeks or 9-12 months to partially return to activity,
Shock wave therapy and Fasciotomy for non-responding cases
16
Q
Where in the body is the majority of all stress fractures?
A
Tibia
17
Q
Tibial stress fracture clinical presenation
A
- Diffuse pain at posteromedial margin of tibia,
palpable localized pain, sometimes with bump. - Insidious and intensifying with activity and persisting at night.
- Tuning fork and one-legged hop test.
18
Q
Ankle Sprain MOI
A
Typically Inversion.
- Eversion/pronation, external rotation and abduction
- Simple deltoid injury = superficial.
19
Q
A complete disrupted ankle sprain
A
talus osteochondral lesion, syndesmotic complex injury, fractures, posterior tibial tendon lesions.
20
Q
Clinical presenation of Low Ankle Sprain
A
- swelling lateral or diffuse
- ecchymosis lateral or sometimes medial heel
- ligaments and bone palpation
- complete ATFL = sulcus sign on anterolateral ankle
21
Q
Physical examination of low ankle sprain
A
- Anterior drawer,
- Anterolateral drawer, talar tilt,
- If severe case, neurological exam to assess peroneal and or tibial n. injury
- proprioception and joint hyperlaxity (Beighton’s)
22
Q
OTTAWA ankle rules (when to x-ray)
A
- pain in malleolar zone and tenderness in A or B,
inability to weight bear both immediate and in emergency department. - pain in midfoot zone and tenderness in C or D, and inability to weight bear
23
Q
Clinical assessment for ankle sprain
A
Involves a Bilateral inspection.
- Swelling/hematoma on the medial side
- Malalignment
- Deformity
If able to bear weight:
Asymmetrical planovalgus and abductus of the affected ankle/foot
Palpation:
- Medial pain
- Tenderness (medial gutter/deltoid ligament/spring ligament)
- Pain/tenderness along the posterior tibial tendon
24
Q
Clinical tests for ankle sprain
A
+ve external rotation test (Kleiger) (superficial layer)
+ve eversion stress test (deep layer) (talar tilt)
+ve anteromedial drawer test
-ve single heel rise test (hindfoot valgus on tiptoe)
25
Management for ankle sprain
- Pain management, ROM, strengthening, proprioception,
- Progressive return to activity, RICE, NSAIDS for pain and swelling (side effects or delay natural healing process), Immobilisation with functional support and exercise therapy, Manual mobilisation
26
Chronic recurrent ankle sprain management
Must always strengthen stabilizers for pronation and supination.
In order of priority:
1. Limited ROM that may have persisted
2. Loss of proprioception
3. Strength
27
Patients with acute LAS have shown similar deficits as CAI within the main impairment domains:
> ROM,
> Strength,
> Postural control, and
> functional activity.
28
How often is the **medial collateral ligament** of the ankle sprained? What are the complications?
- Small % of sprains due to anatomical considerations.
- Can sometimes present with a LAS in very severe cases, management is the same.
**Complications:** non-united avulsions or ossifications, and instability
29
High Ankle Sprain [syndesmotic] MOI
Dorsiflexion associated with external rotation or eversion of ankle
Others can also occur.
- AITFL mc injured
* Tibiofibular syndesmosis interosseous ligament, interosseous membrane, and A + P ITFL
30
High Ankle Sprain [syndesmotic] - clinical presentation
- point tenderness over anterolateral tibiofibular joint (above lateral malleolus)
- pain with weight bearing, passive dorsiflexion, and external rotation, mild to mod swelling in lower leg above ankle.
31
High Ankle Sprain [syndesmotic] : Physical examination/Tests
Squeeze test and External rotation test
32
High Ankle Sprain [syndesmotic] management
- Grade 1 = Conservative
RICE with initial non-weight bearing in a boot followed by early mobilisation
- Grade 2 & 3 = Unstable
likely need surgery
33
Describe the grading system of High Ankle Sprains
* The space between the tibia and fibula should be < 5 mm
* Management will be surgical fixation if the ankle is unstable or if the space is > 1.5 mm compared to normal (6.5 mm or more)
* Spaces in-between the talus and tibia should be relatively congruent medially and superiorly
**Grade 1**
Stable syndesmotic joint with mild tenderness at the distal tibiofibular joint.
Involves the anterior deltoid ligament and the distal interosseous ligament without tearing the more proximal syndesmosis or the deep deltoid ligament.
Grade I injuries are stable because no diastasis is present on the radiograph.
**Grade 2**
Partial syndesmotic ligament disruption with normal radiographic findings A positive external rotation and squeeze test on examination
**Grade 3**
Complete injury to the syndesmotic ligaments.
On plain radiography, there will be an apparent widening of the medial clear space and/or syndesmosis.
All clinical tests are typically positive
34
Synovial Impingement of the ankle
- Chronic painful limitation of ankle motion caused by soft-tissue or osseous abnormalities affecting the tibiotalar joint or extra-articular soft tissues.
35
MOI for synovial impingement of the ankle
- Common after ankle inversion sprains.
- Secondary to: synovitis, fibrotic scar tissue/capsular scarring and osteophytes
- Exacerbated with passive Dorsi-or Plantarflexion
36
Anterior Synovial Ankle Impingement
- ‘Footballers ankle’
- Pain with activity
- Anterolateral joint line tenderness
- Recurrent joint swelling
- Anterolateral pain with forced dorsiflexion and eversion
- Pain during single leg squat
- Lack of lateral ankle instability
37
Posterior Synovial Ankle Impingement
- loss of mobility, with pain in the posterior ankle
- pain with forced plantarflexion
- prominent posterior talar processes
- hyper-plantarflexion test (heel thrust)
- posteromedial joint line tenderness
- anterior drawer test and inversion test
- weakness of the anterior tibialis, peroneus longus/brevis and calf muscles.
38
Management of Ankle Impingement
Conservative care to increase mobility
Rest, ICE, activity medication. NSAIDS, cast immobilisation (severe), shoe modification for more chronic, rehab to improve stability and proprioception, steroid injections.
39
Manual Therapy
Anterior Vs Posterior
**Anterior**
- Distraction manipulation
- A/P and lateral talocrural glides
- A/P distal fibular glides
- Cuboid whip [for decreased pronation]
- HEP: Self A/P and lateral mobilisation, single leg balance, lunge dorsiflexion stretch, progressive ankle resistance exercises
- Lateral ankle stability protocols
**Posterior**
Plantarflexion mobilisation
* P/A talocrural mobilisation
* Rear-foot distraction manipulation
* Proprioceptive work - wobble board
* Peronei strengthening
* Isometric and eccentric exercises to strengthen and stretch the lower-leg muscles
* Exercises to improve deep muscle action during plantarflexion.
* HEP: Achilles tendon stretching, Single leg balance, lunge dorsiflexion stretch, progressive ankle resistance exercises
* Protective dorsiflexion taping
40
Ankle Tendinopathy- Clinical Presentation
- Pain/swelling behind medial malleolus and along MLA
- Change in static/dynamic foot - impaired balance
- Limited walking ability and impaired push off
- Snapping if retinaculum is ruptures
- Decrease muscle strength
- Difficulty with heel raise or inability to. Limited calcaneal inversion upon ascent
- Impaired subtalar mobility
- Lateral ankle pain from sub-fibular impingement = late presentation
41
Ankle Tendinopathy- Risk factors
Diabetes, hypertension, obesity, steroid use, previous injury, foot/ankle trauma, seronegative spondyloarthropathies.
42
Ankle Tendinopathy- Physical Examination
- Palpation elicits tenderness with or without swelling over the retro-malleolar region, the tendon insertion (navicular tubercle) or along entire course.
Not always present :
* Tendon may be palpated as a cordlike structure anterior to the posteromedial ridge of the medial malleolus.
* Resisted inversion of the foot with dorsiflexion or plantarflexion may elicit tendon instability.
43
Ankle Tendinopathy- Johnson and Strom Classificatin
Stage 1:
- Mild swelling and tenderness along posterior tibial tendon.
- Mild weakness.
- Too many toes sign: Absent
- Demoritiy: Absent
- Treatment: Conservative.
Stage 2:
- Moderate swelling and tenderness on posterior tibial tendon.
- Marked weakness.
- Too many toes: Present
- Deformity: Present
- Treatment: FDL transers
Stage 3:
- Not much swelling, but marked tenderness
- Marked Weakness
- Too many toes: Present
- Deformity: Present
- Treatment: Arthrodesis
44
Peroneal /Fibularis Tendinopathy MOI
MOI:
- skiing,
-forceful dorsiflexion with concomitant rapid/strong muscle contraction.
- Inversion and plantarflexion can also occur
45
Peroneal /Fibularis Tendinopathy
Clinical Presentation
- Lateral ankle pain behind malleolus, associated swelling and tenderness
- Elicited symptoms with resisted eversion
- Brevis: pain localised to retro malleolar
- Longus: pain on peroneal tubercle and cuboid groove
46
Peroneal /Fibularis Tendinopathy Grading
Grade 1
Retinaculum stripped away from fibula = tendon dislocation
Grade 2
Fibrocartilaginous ridge and SPR is avulsed from posterior aspect of fibula
Grade 3
Bone avulsion of posterolateral aspect of fibular containing cartilaginous rim and flake of bone permitting tendon to slide beneath periosteum
47
Peroneal /Fibularis Tendinopathy Examination
- Passive plantarflexion/inversion and active plantarflexion/eversion may provoke tenderness or pain
- Single stance heel rise and active plantarflexion/eversion against resistance may cause weakness or pain
- Tendon subluxation may be seen with resisted eversion
48
Achilles Tendinopathy Definition and general patient presentation
Non-rupture injury of the tendon, paratenon or both,
- Mc in runners or jumpers
- Chronic cases mc in older
- Tendon rupture remains common in elite athletes and weekend warriors (M>F)
- Paratenon surrounds the tendon
- Poorly vascularised but paratenon supplies vasculature to the anterior tendon portion greater than other portions
49
Achilles Tendinopathy Risk factors
* Stop and go activity,
* Previous Achilles tendon problems,
* Sudden increase in duration or intensity of training,
* Poor footwear,
* Male,
* Obesity,
* Increased age,
* Poor running mechanics
50
Achilles Tendinopathy
51
Achilles Tendinopathy - Insertional Clinical Presentation
- Pain, swelling, burning and stiffness to posterior midline of tuberosity
- Tendon load is painful
- Worse at night or rest, and with restart of activity
- Pain on palpation
- Aggravated with activity such as running, going uphill/stairs
- Pain is anterior, lateral, or less frequently medial, bursitis should be suspected
- Increase stiffness and limited dorsiflexion
- Silfverskiöld test done to rule out gastrocnemius contraction
52
Achilles Tendinopathy - Non-Insertional Clinical Presentation
- Common in males and runners
- Pain with loading (walking, running) at start of exercise and shortly after completion
- Can be delibitating
- Fusiform swelling
- Tight gastrocnemius
53
Achilles Tendinopathy - Rupture - Clinical Presentation
- Sudden force exerted on tendon
- Feeling of being struck behind ankle
- POP can be heard
- Acute severe pain
- Occurs when pushing off with foot (contrary to ankle sprain landing]
- Mid-substance rupture
; mc with repetitive jumping, sprinters
54
Achilles Tendinopathy Clinical Assessment
- Plantarflexion, ability to walk or lack tendon pain on palpation
- Inspection for bruising, swelling or foot misalignment
- Vascular examination
- Palpation for tenderness, thickening, defects, oedema.
- Pain location on palpation (important for differential diagnosis)
- Thompson, Matles test and Arc sign
55
Achilles Tendinopathy Functional Assessment
Ankle ROM , Heel-rise test for calf endurance, Dynamometry for calf strength, jumping ability
56
Achilles Tendinopathy
**Clinical practice guidelines**:
A diagnosis can be made when 2 or more of the following exam findings are noted:
* +VE Thompson test
* Decreased plantarflexion strength,
* Palpable defect distal to the insertion site, or
* Increased passive ankle dorsiflexion at rest (Matles test)
57
Achilles Tendinopathy- Diagnostic imaging
- MRI is most definitive although some asymptomatic subjects can show signs of tendinopathy while symptomatic can exhibit normal features.
58
Achilles Tendinopathy - Treatment
- Can take a year or more and reinjury is common
- Conservative tried for at least 4 months:
- Activity modification (avoid hills etc.)
- Rest, Ice, Heel lift
- Immobilisation [rigid taping/boots]
- Shock wave therapy
- Eccentric exercise training
- injections
- platelet rich plasma
59
Achilles Tendinopathy: Chronic midportion tendinopathy treatment
- resistance exercises with heavy loading
- eccentric portion of exercise movements or both eccentric and concentric movements (heavy, slow resistance rehabilitation]
- Modified Alfredson’s protocol for insertional is recommended
60
Achilles Tendinopathy:
Rupture Management:
- Calf muscle is strengthened increasing load through sitting heal raises and bilateral heel raises (ultimately to perform single leg heel]
- After 12-16 weeks: jogging
- 16-20 weeks return to non-contact sport
- 20-24 weeks contact sports
61
Achilles Tendinopathy: Functional Criteria to return to activity
For returning to jogging and sport include the recovery of the calve muscle strength, ankle ROM and other sport specific tests.
62
Surgical vs Non-surgery For Achilles Tendinopathy
Based on previous studies comparing surgery vs non-surgical care, no surgery treatment for functional rehabilitation reduces surgical complications without increasing the risk of re-rupture
63
Pathophysiology of Degenerative and Mechanical Achielles tendinopathy
1. **Degenerative**: chronic changes lead to rupture without excessive loads.
2. **Mechanica**l: different movement and forces exerted can lead to tendon failure
- Repetitive or excessive loading appears to be the most common for tendinopathy
- Cumulative microtrauma can lead to tendon damage that is adaptive or non-adaptive.
- Recurrent microtrauma causes degeneration
- Healing is hampered because of the relative tendon mid-portion hypo vascularity (2-6cm from insertion)
- Clinical signs of inflammation swelling, warmth and pain can occur
- Ultrasound can show abnormal neovascularisation of the tissue
- Aging and vascularis disease decrease collagen density cross links and reduce elasticity
- Rupture from sudden shear stress is applied to a tendon already weakened or degenerated
64
A damaged tendon can become?
1. Calcified,
2. Thicken
3. Inelastic and
4. Fibrotic (nodules)
65
Tarsal Tunnel Syndrome Extrinsic and Intrinsic Aeitiological factors
* **Extrinsic**: poor fitted shoes, trauma, anatomical-biomechanical abnormalities, post-surgical scarring, systemic diseases, generalized LE oedema, systemic inflammatory arthropathies
* **Intrinsic:** Tendinopathy, tenosynovitis, perineural fibrosis, osteophytes, hypertrophic retinaculum and space occupying or mass effect lesions
66
Tarsal Tunnel Syndrome: Clinical Presentation
- Vague plantar burning foot pain
- Paraesthesia, numbness, atrophy of intrinsic foot muscles as the condition worsens
- Pain usually aggravated with activity (extreme dorsiflexion and eversion) and relieved with rest
- 50% report cold sensation along medial and lateral plantar nerve
- Tenderness upon palpation of medial malleolus region over tunnel
- May have weakness with toe flexors because tibial nerves motor branches innervate plantar muscles
67
Tarsal Tunnel Syndrome: Clinical Examination
- Ve+ Tinel sign
- Dorsiflexion-eversion test
- Trepman test [plantarflexion + inversion = pain or numbness]
- Triple compression tests
- Gait analysis
- Neurological examination [light touch and 2 point discrimination]
- Foot strength deficits [typically in late stage]
68
Tarsal Tunnel Syndrome: Management
- Conservative for 12-24 months unless severe
- Rest head/cold
- NSAIDs, corticosteroid, GABA medication, tricyclic antidepressants, vit B complex
- stretching/strengthening of gastric, soleus, tibialis anterior/posterior, peroneals, and short toe flexors
- custom orthotics [foot overpronation and supporting long arch]
69
Tarsal Tunnel Syndrome: Orthopaedic assessment
1. Tinel sign,
2. Dorsiflexion eversion,
3. Triple compression
70
Plantar Fasciitis
Risk factors:
- Excessive femoral anteversion;
- lateral tibial torsion,
- LLD,
- hyper pronation,
- innapropriate footwear,
- muscle tightness
-, obesity,
- overtraining.
71
Plantar Fasciitis: Clinical Presentation
- heel pain upon weight bearing ; worse in morning with first steps
- stomach sleepers
- pain gradually improves with activity and returns with prolonged weight bearing
- associated with arthritic conditions and diabetes [weak intrinsic foot muscles and predisposition to inflammation]
72
Plantar Fasciitis: Examination findings
- point tenderness on the medial calcaneal tuberosity
- Pain exacerbated with passive dorsiflexion or active plantar flexion and forced dorsiflexion of big toe (Windlass test]
- most import DDX is tarsal tunnel syndrome
73
Plantar Fasciitis: Investigations
- Ultrasound gold standard with swelling of fascia typical feature
- x-rays not essential for Dx but may show calcaneal spur
* approx half of patients will have heel spurs
74
Plantar Fasciitis: Orthopaedic test
Windlass Treatment
75
Plantar Fasciitis
Short term vs Long term treatment/management
**Short term **
* Avoid aggravating activity
* Cryotherapy after activity
* stretching of fascia, gastric and soleus
* Self massage
* NSAIDS
* Support tape
**Long term**
* Strength exercises for intrinsic foot muscles and for proximal muscle groups
* Biomechanical correction with orthotics
* Night splints
* Soft tissue therapy
* Education for patients
* Surgery if symptoms remain despite appropriate treatment
76
Plantar fasciitis vs Tarsal Tunnel Syndrome
Causes
Pain
Active ROM
Passive ROM
RIM
Sensory deficits
Reflexes
**Plantar fasciitis**:
**Causes:** Overuse
**Pain**: Plantar aspect, anterior calcaneus. Worst with walking,running and in the morning.
**Active ROM:** Full
**Passive ROM**: Full
**RIM**: Normal
**Sensory deficits**: No
**Reflexes**: Normal
**Tarsal Tunnel Syndrome**
**Causes**: Trauma, lesion, inflammation, inverseion pronation, valgus deformity
**Pain:** Medial heel and MLA. Worst when standing, walking and at night.
**Active ROM**: Full
**Passive ROM:** May have pain in pronation.
**RIM:** Weak foot intrinsics
**Sensory deficits:** Possible
**Reflexes:** Normal
77
Plantar fasciitis DDx
Tarsal Tunnel Syndrome
Heel Spurs
Fat pad syndrome
78
Interdigital [Morton’s neuroma] neuralgia: What nerve is affected?
Common peroneal nerve -
Perineural fibrosis of the common digital nerve
79
Interdigital [Morton’s neuroma] neuralgia: Causes
Abnormal foot posture
Footwear with narrow toe box
80
Interdigital [Morton’s neuroma] neuralgia most commonly affects
- mc between 3rd/4th metatarsal, with neuropathic pain to associated toes
81
Interdigital [Morton’s neuroma] neuralgia
Clinical Presentation
* pain radiating into toes [pins and needles and numbness]
* Increased by forefoot weight bearing activities and narrow fitting footwear
* webspace tenderness and toe-tip sensation deficit may be
- Exam reveals localised tenderness , and in chronic, palpable click on compression of the MT head.
82
Interdigital [Morton’s neuroma] neuralgia orthopaedic test
Morton’s forefoot
83
Metatarsalgia Define
pain over metatarsal heads without obvious diagnosis
84
Metatarsalgia general treatment
- Strengthening plantar muscles
- Footwear with low heels and wide-toe boxes
- Orthotics if required
85
Metatarsalgia Prevalant causes
- Obesity
- Inappropriate footwear
- Tight Achilles tendon
86
Metatarsal Stress Fracture Risk factors
Excessive alcohol consumption,
smoking,
sudden increase in physical activity with limited rest periods,
females, vitamin D deficiency,
long distance running.
87
Metatarsal Stress Fracture symptoms
Focal tenderness and swelling
88
Hallux Valgus:
Lateral Deviation of big toe towards other toes.
89
Hallux Valgus can lead to
bunion formation
90
Cause of Hallux Valgus
MC: hyper pronation leading to excessive force on the first ray
- high heels [downward medial force on talus and or tight AT]
- narrow footwear
91
Hallux Rigidus or OA History
- mc degeneration process of the foot
- first MTP
- Affects 1 in 40 > 50 years
- 2:1 females
92
What is the importance of the 1st MTP
plays important role during gait
93
Hallux Rigidus or OA Examination
- tenderness at MTP joint, esp over dorsal aspect
- pain/limit joint motion and restriction reflects arthrosis severity
- plain x-rays display degenerative OA
94
Hallux Rigidus or OA: Conservative management
initial reduction in activity, NSAIDS, injections if required, manual therapy, correction of biomechanical factors with orthoses/ footwear and dynamic splitting
95
The Lower Extremity Functional Scale score
- 0 = high functional disability
- 80 = no disability
96
The Foot and Ankle Ability Measure (FAAM) score
29 questions
- A low score = high disability
97
Pain Catastrophizing Questionnaire Score
- total score ranges between 0 – 52
- An overall score > 30 is considered (75th percentile)
a clinically relevant level of catastrophizing
