Nonsurgical Ankle Disorders Flashcards
Plantar Fasciosis/itis
inflammation of the plantar fascia or chronic fibrosis
Usually near its insertion into plantar calcaneus
Plantar Fasciosis/itis may or may not be associated with
a heel spur - presence of spur is not significant and not associated with inc in symptoms
Plantar Fasciosis/itis - xrays
not indicated initially, only if pain does not decrease
Plantar fasciosis/itis - etiology of the spur
Uncertain
dystrophic calcification secondary to prolonged inflammation of fascial insertion
Dystrophic calcification in intrinsic mm origin
Chronci stress reaction (fracture?) at muscle origin
Plantar Faciosis/itis - Pes planus exerts
passive stretch on fascia
Plantar Fasciosis/itis - Pes cavus causes
increased pressure under the calcaneus
Plantar Fasciosis/itis - may have
concomitant bursitis, neuritis under heel
May be enthesopathy secondary to inflammatory arthropathy
s/s with Plantar Fasciosis/itis
- Post static dyskinesia (pain after NWB)
- Pain with palpation confined to medial plantar calcaneal tuberosity
- Swelling is rarely seen
- May feel better with heel elevated in shoe
- NSAIDs often ineffective
- Pain with passive DF
- Cushioning under heel is inaffective
- MRI, bone scan, ultrasound may confirm path when tx is ineffective
Tx for Plantar Fasciosis/itis
*Restore pressure under longitudinal arch with an arch support
1. Try Spenco 3/4 length arch cushion to start
Ice more effective than heat
2. Night splint
3. Strengthen arch
4. Massage arch
Tx for Plantar Fasciosis/itis - Spenco
Use the length arch cushion with extra arch support and heel accomodative pads fashioned from adhesive felt and attached at top of insert
Plantar Fasciosis/itis - Night splint
Ankle DF 5-10 degrees and toes DF 35 degrees with wedge
Works best when fascial pain is non-insertional
Plantar Fasciosis/itis - Stretching of gastroc-soleus and Achilles or just plantar fascia
RCT showed both relieve pain but just DF the digits (not the ankle) provided more sustained relief
Plantar Fasciosis/itis - stair exercise
Stand on a step at the bottom of the stairs and hold the handrail for balance
Slowly lower your heels as far as you can - 10 times
Lateral ankle sprains involve
3 lateral collateral ligaments
Anterior talofibular
Calcaneofibular
Posterior talofibular
ODonoghue or West Point classification of sprains
1st = ligament is stretched with minimal fibrous disruptions 2nd = rupture of significant portion that leads to instability 3rd = total ligamentous failure has occured
Mechanism of injury for lateral ankle sprain
Mos common is landing on a PF and inverted foot (talus post narrower part moves into wider part and is unstable)
Lateral ankle sprains - order
ATF > CF > PTF (rarely)
High ankle sprain
rupture of the anterior tib-fib ligament and syndesmosis occurs with ankle in DF and ER force is applied (lineman)
Anteriot Drawer - Positive test
4mm or more of anterior displacement compared to uninjured ankle
Stress Inversion test - positive test
CF ligament
6 degrees or more (btw ankle and tibia) varus tilt compared to uninjured ankle
High ankle sprain is of what and strongly suggests what
Ant Inf Tibial-Fibular ligament
Suggests syndesmosis rupture
VERY UNSTABLE
How to confirm a high ankle sprain
Produce pain with ER a PF foot or squeezing the distal tibia and fib together just above midcalf level
Stable vs. Unstable Grade 2 high ankle sprains
Positive ER test, Positive squeeze test, and pain with palpation of ant tib/fib lig and deltoid lig - if all these is as reliable as an arthroscopy - but if dont have all four doesnt mean you dont have it
Treatment ankle sprain - Grades and sport activity time lost
Grade 1 = 1-2 weeks lost from sport
Grade 2 = 2-6 weeks
Grade 3 = 4-26 weeks
Treatments for ankle sprain
NSAIDs for pain relief and limit swelling
Continue ice until sweling is gone or painfree WB
If pain with weight longer than 7 days consider BK walking cast or CAM walker with ACE wrap
Treatment for ankle sprain - ROM
Start ankle ROM exercises when NBW (write alphabet)
When ROM exercises are pain free start strengthening and stretching
Ankle Sprain - Isometric strengthening exercises are used for
rehabing the peroneals which often are weak after an ankle injury and can lead to instability
Ankle sprain - stretching of the achilles tendon is necessary why
dec ankle joint DF places the narrow post talus further distally in wider ant ankle joint - most unstable position of the ankle
People with ankle sprains may have tight achilles so youd want to stretch it and make it more flexible to prevent further injury
Isotonic strengthening - ankle sprain - used for
anterior msucle group
Isometric and then isotonic
Ankle sprain - important to do proprioception because
residual instability may be a result of damage to the afferent nerve fibers in the capsule
Proprioception exercises for people with ankle sprain
stand on injured foot, first with eyes open and then with eyes closed
Continue until patient can balance on one foot for one minute with eyes closed
Ankle sprain - proprioception - you can also use a
BAPS board and have patient stand on one foot in center and rotate disk clockwise and then counterclockwise with eyes open and then with eyes closed
Ankle sprain - return to full activities when?
when able to stand on toes of ankle for 20 seconds and hop on toes 10 times and can cut and run a figure of eight
Ankle sprain - bracing
use bracing for at least 6 months
Nonbraced athletes have 3 times the risk of injury
Ankle sprain - orthotics
especially USB insert, to limit varus deformities
Ankle sprain - type of shoe
High topped laced athletic shoes
Ankle sprain and taping
He doesnt recommend it - provides 10% inc in max resistance to inversion moments but after 40 min of exercise is not protecting anymore
Ankle sprain - re eval
Consider re-eval with bone scan to rule out occult fracture if sx do not dec within 2 wks of initiating therapy
Ankle sprain predicting chronic ankle instability
You can predict it after first ankle sprain by having them complete jumping and landing tasks within first 2 weeks of first time LAS
Posterior Tibial Tendonitis
Most common cause of medial ankle pain, especially without identifiable trauma
Most common etiology of PTT dysfunction is
pronation
Other causes of PTT
obesity, inflammatory arthritis, oral or injectablle steroids
S/S of PTT
Pain usually with noticeable swelling, along medial aspect of ankle and rearfoot
Noticeable flatfoot
Too many toes sign - due to increased forefoot abduction
Treatment PTT
Base on stage of deformity
Usually all early or stage 1 deformities will respond to conservative care
Treatment PTT - conservative care
Flexible foot
Mild weakness on single heel rise
Absence of too many toes sign
Stages 2 to 4 require surgery
Orthotic for PTT
UCBL device
Best option might be a Richie brace though
Can consider an AFO but usually too bulky and bothersome for patient
PT is a must
Steroid injection into tendon body is contraindicated
Achilles Tendinopathy - Most pathologies occur
3 to 6cm above the insertion of the achilles
Achilles Tendinopathy - area of
Poor vascular supply (watershed area)
Achilles tendinopathy can be
insertional or noninsertional
Achilels tendinopathy - insertional is often associated with
calcification of tendon substance
Etiology of achilles tendinopathy
Can be short gastroc-soleus
Excessive uphill running (passive DF stretching tendon)
Sport that involves more toe standing
Pronation or pes cavus foot
Too flat a shoe
Inflammatory arthropahty with enthesopathy
Diagnostic imaging for achilles tendinopathy
MRI, ultrasound
Other ways to diagnose an achilles tendinopathy - rupture
Thompsons test - but know that false pos can occur
Very little pain with dramatic inc in passive DF
What can you see or feel with an achilles rupture
dell (feels like dead space) along the post aspect of the achilles where the rupture ocurrred
Tx for tendinopathy
RICE Min of 3/8 inch heel lift NO stretching until tendon pain eases (eccentric) Topical diclofenac Iontophoresis NSAIDs Orthotics Cast immob
Problematic fractures
5th metabase
calcaneal joint depression
Ankle syndesmotic rupture
5th Metabase fracture - when confined to tuberosity
NWB, BK cast immob for 6 weeks
5th metabase fracture - when somewhere btw 1.5 to 3cm from the tip of the tuberosity is called a
jones fracture and in an athlete surgery is accepted as tx of choice
Jones frcture has a reputation as
a poor healer
literature says that conservative tx or surgical care is successful at healing though
Calcaneal joint depression fracture - at impact what happens
the posterior facet of the calcaneus is driven plantarly into the body of the calcaneus by the lateral talus
Calcaneal joint fracture outcome
extrememly poor with or without surgery
Calcaneal joint fracture - ROM and WB
Early ROM and NWB
Boot in neutral position
Compression stocking
Types of ankle fractures
Unimalleolar
Bimalleolar
Trimalleolar
Syndesmotic
With an ankle fracture dont forget to look for
fibular fracture AND medial malleolar fracture
Most common type of ankle fracture
Spiral oblique fracture of the fibula starting at level of ankle joint
75%
Most serious and longest healing ligament injury involves what and is what
Ant-Inf tibial-fibular ligament and involves damage to the syndesmosis
Ant Inf Tib Fib ligament injury with syndesmosis will have pain with
ER of the foot on passively PF ankle (Kleiger)
May have pain with squeeze
Only reliable detection of rupture is intra-operatively
