ortho - foot & ankle Flashcards
lateral ligament injury
- 14-21% of all sports injuries
- 85% of all ankle injuries
- 85% involve lateral inversion mechanism
- Most resolve with little medical intervention, and recurrent instability occurs in 15% to 48% of these injuries
stabilisers of ankle
bony
- fibula (lateral malleolus)
- tibia (articular surface & medial malleolus)
- talus
soft tissue stabilisers (static& dynamic)
- talofibular ligament
- calcaneal fibular ligament
lateral ankle ligaments
- Anterior talofibular ligament (ATFL)
- Calcaneofibular ligament (CFL)
- Posterior talofibular ligament (PTFL)
medial ankle ligaments
- superficial deltoid
- deep deltoid
ankle syndesmosis ligaments
- Anterior-inferior tibiofibular ligament (AITFL), - posterior-inferior tibiofibular ligament (PITFL),
- distal interosseous ligament (IOL)
acute injury
- mechanism of injury: inversion & plantar flexion
- pain
chronic injury
- instability (1/more injuries, repeated sprains)
- swelling
- pain
- locking (osteochondral #)
Factors Contributing to Chronic Ankle Instability
- Mechanical
* Pathologic laxity
* Arthrokinetic restriction
* Synovial changes
* Degenerative changes - Functional
* Impaired proprioception
* Impaired neuromuscular control
* Impaired postural control
* Strength deficits
ankle clinical examination
- INSPECTION
* Ecchymosis
* Swelling
* Blister formation
* Gross deformity - PALPATION
- MOVEMENT
* Pt. seated & relaxed knees flexed
* Check maximal DF & PF - Muscle testing
* Strength & pain - Pulses
Dorsalis Pedis, Tib. Post - Sensation
- Generalised ligamentous laxity
ankle clinical instability test
ANTERIOR DRAWER TEST
* 20 ̊ plantar flexion
* Tibia stabilised & foot pulled forward
TALAR TILT TEST
* Tilting of hindfoot (varus/inversion)
* ?suction sign
* Palpate talar neck (ankle vs. subtalar jt.)
ankle clinical radiography
- stress radiographs (indication abnormal clinical stress tests (chronic))
- Arthrograms
- CT
- MRI
- Ultrasound
ankle management - phases of healing
- Inflammatory:
PRICE protocol
(Up to 10 days) - Proliferative:
motion and strength, improve co-ordination & proprioception
(Up to week 4-8) - Remodelling:
endurance training, sport- specific drills, & training to
improve balance
(Up to 1 year)
ankle management - initial / inflammatory phase
- Protection
* Casts/ moonboots
* Small advantage with lace up braces - Rest
- Ice
early cold therapy (within 36 hours) - Compression
* Elasti cbandage, casting, splinting, pneumatic orthoses - Elevation
Prolonged immobilisation is not recommended
acute ankle management
- Cast immobilisation
- Early mobilisation
- Surgical repair
acute ankle management - functional method of rx
- Sufficient recovery / Early mobilisation
- Avoids immobilisation
- Flexibility & strengthening
- Closed chain activities (endurance & balance)
- Aerobic fitness is maintained with cross-training activities such as water running & cycling.
acute ankle management - surgery
Indications
* Open injuries
* Large avulsion #
* Frank dislocation
* High demand athlete (with recurrence/chronicity)
acute ankle management - lateral ligament reconstruction
- safe and effective treatment for acute severe ruptures
- providing a stable ankle
- return in approx. 10 weeks
acute ankle mx - functional rx ineffective, still pain & swelling =
- Recurrent instability
- Peroneal tendon injury
- Osteochondral injury
chronic ankle management - conservative
- Functional ankle bracing
- Rehab + decrease activity levels
* Peroneal motor strengthening
* Proprioception
* Co-ordination
* Effective in 50%
chronic ankle management - surgery
indications:
* Failed rehabilitation
* X-ray
- Talar tilt >15 ̊(>10 ̊ of other side)
- Anterior translation >5mm (>3mm of other side)
conclusion rx for acute & chronic
acute
- functional method of rx
- acute repair for sportsmen
chronic
- surgery
- anatomical repair
plantar fasciitis
- Principle static and dynamic stabiliser longitudinal arch
- Shock absorber (sole of foot)
- Chronic inflammation
- Bony traction spur
plantar fasciitis - clinical symptoms
- 30 – 60 years
- Pain, swelling, difficulty walking
- 1st Step after inactivity worst
- Antalgic gait
- Point tenderness over medial calcaneal tuberosity
- Pain exaccerbated on tip toes/ hallux stretch
plantar fasciitis - diagnosis
- Mainly clinical
- Ultrasound
- Bone scan
- MRI
plantar fasciitis - DDx heel pain
- Calcaneal bone lesions
- Stress fractures
- Insertional Achilles
- Tib post tendonitis
- Heel pad atrophy
- Painful fat pad
- Nerve entrapment
- Calcaneal branch posterior tibial nerve
- Between deep fascia abductor hallucis and quadratus plantae muscle
- Tarsal tunnel syndrome
plantar fasciitis - aetiology / cause
- Mechanical overload – obesity, tight TA, excessive pronation
- Repetitive micro tears – chronic inflammation
- Calcaneal spur not causative
plantar fasciitis - conservative mx
- Rest
- NSAID’s
- Stretching-Achilles and PF
- Heel cushions
- Orthotics
- rigid night splints, dorsiflexion
- Ice/Heat
- Taping – reduces load transmission
- Hydrocortisone injection
- Extra corporeal shock wave therapy
- Radiotherapy
- Botulinum toxin
plantar fasciitis - surgical mx
- Emphasis on partial release
- Open release
- Percutaneous release
- Endoscopic fasciectomy
- Radiofrequency lesioning
- Complete release
- Loss of windlass mechanism
- Increased bony stress reaction of calcaneus * Increased strain on plantar CCJ capsule
- Increased stress long plantar ligament
- Increased stress 2nd MT head
