lower limb, ankle, & foot injuries Flashcards
what should you look for in lower limb posture analysis (static)
- look for symmetry
- alignment: shoulders, ASIS, achilles, etc.
- muscle contracture - tension through muscles
what should you look for in gait analysis (dynamic)?
look for functional work
- how does the muscle look when you move
- general stride length - symmetric
- stride width
- time spent on each leg
- normal movement through each phase
coxa vara - def
deformity of the hip, whereby the angle between the head and the shaft of the femur is reduced to less than 120 degrees
coxa valga - def
deformity of the hip where the angle formed between the head and neck of the femur and its shaft is increased, usually above 135 degrees
at which angle does the head of the femur normally sit in the acetabulum?
typically between 125 and 140 degrees
femoral anteversion - def
inward twisting of the femur
-toed in position
femoral retroversion - def
femoral neck is rotated backward on the femoral shaft
-toed out position
femoral ante/retroversion can come from _____ or ____ rotation
hip, tibial
patella alta - def
unusually small knee cap (patella) that develops out of and above the joint
patella baja - def
abnormally low lying patella
genu recurvatum - def
deformity in the knee joint, so that the knee bends backwards
-aka hyperextension
internal tibial torsion -def
inward twisting of the tibia
-toed in position
external tibial torsion - def
outward twisting of the tibia
-toed out position
pes cavus - def
-abnormally high arch in the foot
pes planus - def
-collapsed arch of the foot
tibial contusion - etiology
- prone to severe contusions due to lack of adipose and muscular padding
- can palpate all along the anterior border
- repetitive blows can result in periosteum damage
S&S of tibial contusion
- hematoma
- inflammatory phase - POLICE
what are possible secondary conditions of tibial contusions?
-osteomyelitis, anterior compartment syndrome, tibial fracture
tibial contusion management
POLICE and protect upon RTP
Key: PREVENTION - or prevent re occurrence
gastroc contusion - S&S
- hemorrhaging and muscle spasm quickly lead to a tender, firm mass that is easily palpable - similar to quad contusion
- immediate pain and weakness (when contraction or pushing off during walk)
- myositis ossificans - not as common in calf
gastroc contusion - management
- POLICE - ice and compression with muscle stretch
- gentle ROM and stretching exercises - minimize scar tissue
- if it does not improve in 2-3 days - ultrasound may be used to assist in breaking up the hematoma
- gentle massage to bring blood up towards body - gravity will pull it down; wrap distal to proximal, same with massage
compartment syndrome is usually involved in which compartments of the leg?
anterior and deep posterior
what are the 4 compartments of the leg and what are their functions
1) anterior: dorsiflexion
2) lateral: eversion
3) superficial posterior: plantar flexion - power muscles
4) deep posterior: plantar flexion and inversion
what are the 3 different types of compartment syndrome?
1) acute - from a direct blow
- intense swelling, distal pulse diminished, compromised vasculature and nerves, numbness and tingling
2) acute exertional - minimal to moderate activity
- build up of pressure
3) chronic - symptoms develop when activity stops
management of acute compartment syndrome
- acute - ice and elevation
- CONTRAINDICATIONS: compression - do not wrap
- chronic - activity modification and stretching
- fasciotomy in a medial emergency (Acute) or failed conservative treatment (Chronic)
why are eversion ankle sprains less common than inversion?
due to bony and ligamentous support on the medial side of the foot
-an avulsion fracture will often occur rather than a deltoid ligament sprain
which takes longer to heal? inversion or eversion ankle sprain?
- eversion
- because of possible secondary avulsion fracture and the fact that it’s a larger and stronger ligament
grade ___ or ____ eversion ankle sprains produce significant ankle instability and weakness in the medial longitudinal arch
2, 3
management of eversion ankle sprain
- POLICE
- strength, balance/agility exercises
- progress to functional movement, static is good but not relevant to sport
syndesmosis “high ankle” sprain - MOI
- DF and external rotation
- results in damage to anterior and/or posterior tibiofibular ligaments
- interosseous membrane affected in more severe injuries
- often misdiagnosed
S&S of high ankle sprain
- severe and prolonged pain
- ankle and anterolateral leg, increased with passive external rotation and DF
what special test can be used to diagnose high ankle sprains?
Kileger’s and squeeze test
management of high ankle sprain
- prolonged NWB with crutches or walking boot
- delayed return to functional activities
- NM control and proprioception important
ottawa ankle rules
- clinically very difficult to differentiate a # from a severe sprain without an x-ray unless there is obvious deformity
- ottawa rules introduced in 1992 to reduce the number of unnecessary xrays, while at the same time minimizing the number of #’s missed - have been validated; 97.8% sensitivity
- ankle xray is only required if there is any pain in the malleolar zone and bone tenderness posterior edge or tip of LM and MM; inability to WB both immediately and in the ER
- foot xray is required if there is any pain in the mid-foot zone and tenderness at the base of the 5th MT or navicular; inability to WB both immediately and in the ER
fractures of the tibia/fibula; transverse, linear, oblique, or spiral - MOI
- direct blow or twisting with foot planted
- tibia most common at middle 1/3; fibular most common at distal 1/3
avulsion fractures of the tibia/fibula - MOI
- 2nd or 3rd degree inversion or eversion sprain
- medial or lateral malleolus
cuboid subluxation is often a secondary condition to _______
inversion ankle sprains
S&S of cuboid subluxation
- pain on anterior/lateral ankle and along 4th and 5th MT
- refers pain to heel (often confused with plantar fasciitis)
- pain increases with standing after prolonged NWB period
- pain due to stress on fibularis longus muscle when foot is pronated
management of cuboid subluxation
- manual manipulation offers immediate pain relief and able to RTP
- tape or orthotic to minimize chance of recurrence
Lisfranc injury - etiology
tarsometatarsal fracture/dislocation
- dorsal displacement of the proximal end of the metatarsals
- uncommon injury, but causes long-term disability
Lisfranc injury - MOI
- ankle locked in PF; forces hyper-plantar flexion of forefoot
- dorsum of foot rolls forward with BW providing force to displace MTs dorsally
S&S of Lisfranc injury
- can be relatively subtle
- pain and inability to FWB
- swelling and tenderness over dorsum of foot
management of Lisfranc injury
- POLICE - splint and NWB with crutches
- physician referral
- assess for MT fractures and joint sprains
- open reduction with internal fixation often required
what is a potential complication of a Lisfranc injury?
metatarsalagia
metatarsalagia - def
- general term describing pain under the ball of the foot
- commonly pain under 2nd or 3rd metatarsal head
- flattened transverse arch and depressed MT heads
there are many causes to metatarsalagia, but what are the common ones?
- limited extensibility of the gastroc-soleus complex
- fallen metatarsal arch
management of metatarsalagia
- padding behind metatarsal heads to elevate depressed heads
- stretching gastroc-soleus complex
- strengthening tow flexors and intrinsic foot muscles
intrinsic causes for metatarsalagia
- excessive body weight
- limited extensibility of G-S complex
- fallen MT arch
- valgus heel
- pes planus or pes cavus
extrinsic causes for metatarsalagia
- narrow toe box
- improperly placed shoe cleats
- improper technique
- landing incorrectly from a height
- repetitive jumping or excessive running
- running style puts undue pressure on forefoot
morton’s neuroma - def
- mass about the common plantar nerve sheath between the 3rd and 4th metatarsal heads
- nerve is the thickest at the point where it divides into the 2 digital branches
S&S of Morton’s neuroma
- burning paresthesia and severe intermittent pain in forefoot and radiating to the toes
- collapse of the transverse arch
- hyperextension of toes on WB (squatting, stair climbing, running)
- wearing shoes with narrow toe box or high heels
-pain becomes constant with prolonged nerve irritation
management of Morton’s neuroma
- teardop pad between 3rd and 4th MT head
- proper shoe selection
turf tow (1st MTP joint sprain) - def
-hyper-extension of the great toe
turf toe MOI
- single trauma or repetitive overuse
- artificial turf due to unyielding surface and more flexible shoes
- jamming into the end of the toe box
S&S of turf toe
- significant pain and swelling around 1st MTP joint
- exacerbated with push off when walking, running, and jumping
management of turf toe
- POLICE and rest until pain free
- shoes or insoles with support (steel) under forefoot
- taping to prevent/limit MTP motion
hammertoe - def
- flexion contracture of the PIP joint
- proximal interphalangeal joint
mallet toe - def
- flexion contracture of the distal interphalangeal joint
- involves the flexor digitorum longus tendon
claw toes - def
- flexion contracture of the DIP with hyper-extension of the MP joint
- caused by wearing shoes that are too short over a prolonged period of time
- blistering, swelling, pain, callus formation, and occasionally infection
subungual hematoma - MOI
- direct blow - stepped on, dropping an object on or kicking another object
- repetitive shearing force on toenail - long distance runner
S&S of subungual hematoma
- extreme pain bc blood accumulated in a confined space - gentle pressure on nail greatly exacerbates pain
- area under toe nail assumes bluish-purple colour
management - subungual hematoma
- ice and elevation immediately to minimize bleeding
- pressure can be released by drilling hole through nail
- should be done by a physician in a sterile environment (high chance of infection)
stress fractures - tibia and fibula - MOI
- overuse stress condition, common in long distance runners
- more common in lower 1/3 of leg
- inexperienced and unconditioned athletes at risk
- amenorrhea and nutritional deficiencies also affect bone structure
- more likely in individuals with structural deformities in the foot
fibula - hypermobile or pronated foot
tibia - rigid pes cavus feet
what are extrinsic factors that make someone susceptible to stress fractures in the tibia/fibula?
sudden changes in training habits, footwear, unforgiving hard training surfaces
stress fractures - tibia/fibula: treatment
rest and reduce loading forces; identify and correct any training errors or bio mechanical issues; orthotics; gradual RTP
fibularis subluxation/dislocation - MOI
fibularis retinaculum (holds fibularis longus and brevis in place) torn allowing tendons to move out of the groove -dynamic foot/ankle activities, direct blow to posterior lateral malleolus, severe inversion ankle sprain or forceful DF
S&S of fibularis subluxation/dislocation
- tendons snap out of groove
- eversion replicates subluxation
- ecchymosis, edema, tenderness, and crepitus
management of fibularis subluxation/dislocation
- conservative: compressing with padding, POLICE (5-6 weeks), gradual exercise progression (ROM, strength, and balance)
- surgery if ocnservative management fails
ankle tendinitis MOI
caused by excessive eccentric contraction
anterior tibialis tendinitis
cause: running downhill
pain with resisted DF and or stretch
posterior tibialis tendinitis
cause: hypermobility or pronated feet
pain with resisted inversion and PF
fibularis tendinitis
cause: pes cavus foot
pain with PF (push off/rising on the ball of foot during activities)
achilles tendon tendinitis
cause: uphill running and excessive jumping; decreased flexibility of gastroc/soleus
pain with toe raises
management of ankle tendinitis
- POLICE
- correct biomechanics - foot positioning via shoes, orthotics, or taping
- rest from aggravating activities
- NSAIDs and analgesics as needed
- stretching routine and warm up exercises
- balance/neuromuscular control
- progression of strengthening exercises - ECCENTRIC is key
medial tibial stress syndrome S&S
- aka shinsplints
- pain along the posterior medial aspect of the lower tibia
- originally thought to be posterior tibialis muscle causing myositis, fasciitis, and periostitis
- now believed to be related to periostitis of hte soleus insertion along the medial tibia - sometimes see shin splints in tibialis anterior insertion point
what are the causes of MTSS
- foot alignment (pes planus or cavus foot; tight achilles tendon)
- weak leg muscles; minimal support/cushioning from shoes, training errors (hard surfaces or overtraining). excessive weight, reduce bone mineral density
when in pain present in different grades of MTSS?
- grade 1: after activity
- grade 2: before and after activity, but not affecting performance
- grade 3: before, during, and after activity that affects performance
- grade 4: so severe unable to perform activity
management of MTSS
- difficult due to multi factorial causes
- physician referral to rule out: stress fracture or exertional compartment syndrome
- ice for localized pain and inflammation
- activity modification
- correct biomechanics (shoes, orthotics, taping)
- stretch gastroc/soleus
- taping: arch support and or shin
what are three different heel conditions?
1) apophysitis of the calcaneus - sever’s disease
2) retrocalcaneal bursitis
3) heel contusion
apophysitis of the calcaneus
- sever’s disease
- traction injury at the apophysis of the calcaneus where the Achilles tendon attaches
retrocalcaneal bursitis
- inflammation of the bursa between the Achilles tendon and calcaneous
- Haglund’s deformity (pump bump) can cause ongoing inflammation of bursa
heel contusion
-irritation of fat pad (inferior to calcaneus) due to impact
talus fracture
- compression fracture often associated with severe inversion ankle sprains
- with DF = lateral dome fracture
- with PF and external tibial rotation = medial dome fracture
- pain with WB, catching/snapping, intermittent swelling and tender on palpation of joint line
-can be in the form of osteochondritis dissecans - displacement of osteochondral fragment on proximal aspect of talus
calcaneal fracture
1) compression: associated with fall from a height or landing from a jump
2) stress: repetitive impact during heel strike in long distance runners
3) avulsion:
- anterior: calcaneal ligament - with inversion and PF
- calcaneal tuberosity: sudden contraction of the Achilles tendon
what are two common metatarsal fractures?
1) Jones fracture
2) March fracture
Jones fracture
- fracture of the diaphysis of the base of the 5th MT
- MOI: inversion with PF, direct force (stepped on), repetitive stress
- immediate pain and swelling of 5th MT
- high non-union rate
- treatment is controversial - crutches with no immobilization vs internal fixation
March fracture
- stress fracture to the shaft of the 2nd MT
- MOI: runners who suddenly increase mileage, run hills or harder surfaces
- predisposing factors: forefoot varus, hallux valgus, flatfoot or short 1st MT (morton’s toe)
