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MSK II - FOOT and ANKLE > Shin Splints and Bone Injuries > Flashcards

Shin Splints and Bone Injuries Flashcards

1
Q

What are the most common structure involved in shin splints?

A
  • Tibialis Posterior, medial tibial shaft, and Soleus
  • MORE common than anterior type (4-19% in athletes)
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2
Q

What anterior structures are involved in shin splints?

A

Tibialis Anterior and lateral tibial shaft

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3
Q

What is the MOST densely innervated tissue involved in shin splints?

A

Periosteum: connective tissue that surrounds bone except on articular surfaces

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4
Q

What is Posterior or Medial Tibial Stress Syndrome (MTSS)?

A
  • Another name for shin splints, involving the tibialis posterior, medial tibial shaft, and soleus.
  • MORE common than anterior type (4-19% in athletes)
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5
Q

What are risk factors for Medial Tibial Stress Syndrome (MTSS)?

A
  • Biological female (Dietary/ Hormonal)
  • High BMI
  • Previous running injury
  • Training errors
  • Impaired LE control
  • Excessive pronation: Increased Navicular drop and Pronation
  • Increased PF ROM: unclear contributions; possibly
    indicating ankle instability leading to excessive pronation
  • Greater hip ER ROM: NOT well understood
  • NO meaningful association with shoe wear
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6
Q

Pronation is eccentrically controlled PRIMARILY by what muscle?

A

Tibialis Posterior

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7
Q

What are the pathomechanics of Medial Tibial Stress Syndrome (MTSS)?

A
  • Excessive tibial bending stresses exceed opposing mm. supply
  • Increased load on deeper posterior leg mm, particularly Tibialis Posterior and Soleus
  • Traction and inflammation of periosteal tissue
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8
Q

What are symptoms of Medial Tibial Stress Syndrome (MTSS)?

A
  • Gradual onset of medial shin P!
  • Generally worsened with exercise and NOT ADLs
  • NO cramping, burning, or tingling
  • 1/3 have co-existing leg injuries
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9
Q

What might you observe with MTSS?

A
  • Overstriding leading to greater heel strike
  • Impaired LQ control
  • Possible excessive pronation
  • Increased pelvic drop… so impaired hip abduction mm.
  • Increased LE IR
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10
Q

PF directly oppose what motion?

A

The bending of your tibia

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11
Q

What might you see with resisted/ MMT with MTSS?

A
  • Weak and possibly P!ful PFs
  • Hip weakness and lack of endurance
  • Ext/abd
  • ERs
  • Possibly weak and P!ful IV
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12
Q

What special tests will you have the patient preform for MTSS?

A
  • P! with hop on ball of foot due to plantar flexion of Tib Post
  • Possible foot and/or ankle instability
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13
Q

What motions do you want to see when you do heel raises?

A

Want to see PF and INV (INV at calcaneus)

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14
Q

Where will the patient be tender with MTSS?

A

TTP over postero-medial tibial border ≥ 5 cm or 2 in. in length

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15
Q

Is POLICED helpful for MTSS?

A

Yes

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16
Q

What basic patient education should you provide for MTSS?

A
  • Soreness rule
  • Load management
  • LQ control
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17
Q

What kind of movement pattern training education should you provide your patient?

A
  • NOT changed by strengthening alone
  • Reduce LE IR with cues to tighten glutes
  • Decrease heel strike with cueing for shorter/faster steps
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18
Q

What kind of shoe wear (general instruction for all runners) should you provide your patient?

A
  • Light, supportive, and cushioned
  • Rotate shoes- 39% lower injury risk
  • Change running shoes every 250-500 miles
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19
Q

What kind of taping/ orthotics should be done for MTSS?

A
  • Taping to assist Tibialis Posterior
  • Foot orthotic
  • For excessive pronation use pre-fabricated orthotic
  • For heavy heel striker use
  • Cushioned inserts
  • Gel heel cups
  • Air-cast for functional support that allows ankle motion (Unloading bone)
  • Walking boot in severe cases
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20
Q

What is manual therapy good for with MTSS?

A

Any joint dysfunctions like limited DF

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21
Q

What is the MET primary focus for MTSS?

A

Unloading Tibia and Tibialis Posterior

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22
Q

What else is MET good for with MTSS?

A
  • Improve hip Ext/ER/Abd strength
  • Improve PF and IV strength
  • Soleus- supports up to 8x BW
  • Gastroc/ Soleus- counters distal tibial bending
  • Tibialis posterior is primary invertor
  • Address spinal stabilization prn
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23
Q

What differential diagnosis do you need to reason through with MTSS?

A
  • Bone stress injuries of Tibia: Stress reaction (periosteal and/or marrow inflammation) or Stress fracture (cortical break)
  • Compartment Syndrome
24
Q

What is the prevalence/ incidence for bone stress injuries?

A
  • Up to ~16% in recreational or competitive athletes
  • Biological females 3.5x the risk vs. males
  • Most common for runners
25
Q

What are the characteristics of stress fractures in athletes less than 20 years of age?

A
  • Peak at 16 yrs.
  • Basketball MOST common sport
  • Tibia MOST common bone
  • 70% participated 6-7 days/wk.
26
Q

What is the most common bone stress injury for runners?

A

Tibia… progression of MTSS

27
Q

What is the most common area for a bone stress injuries in the fibula?

A

Distal region

28
Q

What is the most common foot injury?

A

Bone stress injury of the metatarsals

29
Q

What is the most common metatarsal prone to AVN?

A

Base of the 5th

30
Q

What are the 3 zones of injury in the metatarsals?

A
  • Zone 1- 90% of fxs and MOSTLY with sprains
  • Zone 2- MOST susceptible to AVN
  • Zone 3- typically due to repetitive stress with possible lack of pronation
31
Q

What are risk factors for bone stress injuries?

A
  • High forces worse than more frequent
  • Repetitive jumping/landing
  • Impaired LQ control
  • Longer stride length leads to greater heel strike
  • LE weaknesses
  • Poor load management
  • Diet and hormonal dysfunction
32
Q

What is the pathogenesis of bone stress injuries?

A
  • Increasing load and frequency without recovery
  • Osteoclastic activity exceeding osteoblastic activity
33
Q

What are symptoms of a bone stress injury?

A

Generally worsening P! with ADLs AND exercise, and
may become constant

34
Q

What are signs of bone stress injuries?

A
  • Typical fx findings
  • Bone P! also reproduced with hop test on heel within 10 reps for Tibial stress fx
35
Q

What might you see on a radiograph (x-ray) with a bone stress fracture?

A
  • fx may NOT appear for 2-6 weeks
  • Unlikely that anything will show up to tell this individual not to participate in their activity … if they continue they will most likely get worst, call doctor… worried about bone!
36
Q

What might you see on a MRI with a bone stress fracture?

A

Gold standard for earlier detection bc of periosteal and bone marrow changes;
NOT reflective of healing

37
Q

Why do diet and hormonal limitations need to be addressed with bone stress injuries?

A
  • Due to possible
    decreased bone mass density (BMD): meeting energy expenditure, Vit. D, Calcium, regular menstrual cycles (estrogen helps absorb calcium)
  • Well managed sleep, stress, and BMI
  • Medications i.e., antacids prevent gut absorption of Calcium
38
Q

Adolescent bone does NOT =

A

Adult bone

39
Q

BMD decreases just before growth spurts and then takes up to _____ to increase afterwards

A

4 yrs.

40
Q

What is the average growth spurt timing for a biological female and male?

A
  • Biological females- 11.9 yrs.
  • Biological males- 13.6 yrs.
41
Q

What is the average age of menarche?

A

12 years

42
Q

Why does it make sense that these adolescence are getting stress fractures?

A
  • There is a period of skeletal weakness around growth spurts
  • They are also are dealing with hormonal and skeletal changes in addition to increasing physical activity
43
Q

What kind of PT Rx can you do with someone with a bone stress injury?

A
  • Graded unloading to ambulate without pain
  • Gradual and progressive return to activity while addressing risk factors and etiologies
  • If it hasn’t been 2 weeks begin treating with caution, if it has been 2 weeks send for x-ray
44
Q

What is the prognosis for tibial stress fractures?

A
  • BMD lowest at 3 mths. post fx in both injured > uninjured leg
  • BMD returned to baseline between 3 and 6 mths.
  • Reinjury to either LE more likely prior to 3 mths. !!!
  • All were at baseline BMD by 6 mths
  • BMD @ 12 mths. surpassed baseline
45
Q

What is the etiology of compartment syndrome?

A
  • Blunt Trauma (ex: kicked in the shin)
  • Overuse
46
Q

What is the pathogenesis of compartment syndrome?

A

Increased swelling with limited fascial extensibility,
particularly compressing neurovascular structures in the anterior leg compartment

47
Q

What are signs and symptoms of compartment syndrome?

A
  • Recent blunt trauma or overuse to anterior compartment
  • Primarily cramping, burning, tingling
  • Any lengthening or use of DFs adds to compression and P!
  • Possible DF weakness
48
Q

What are the 6 Ps in compartment syndrome?

A
  • Pain- severe and persistent
  • Palpable tenderness
  • Pulselessness
  • Pallor- blanching
  • Paresthesias
  • Paralysis
49
Q

If a patient is experiencing “unrelenting 6 Ps” what does this mean?

A

Medical emergency due to neurovascular
compromise and need for surgical fasciotomy to prevent tissue death

50
Q

If you can modify the 6 Ps what does this mean in regards to PT?

A
  • PT should be directed at the source of inflammation and fascial extensibility
  • Surgery may be necessary
51
Q

What is a bi-malleolar ankle (aka Pott’s) fracture?

A

Distal tibia and distal fibula

52
Q

What is a tri-malleolar ankle (aka Pott’s) fracture?

A

Tibia, fibula, and posterior tibial rim

53
Q

What is the most common rearfoot tarsal fracture?

A

Calcaneus MOST common tarsal fx

54
Q

Are fractures in the midfoot common?

A

Rare except the navicular

55
Q

What is the most common foot region of fractures?

A

Forefoot

56
Q

What is the PT Rx for fractures?

A

Primarily treating consequences of
immobilization of other tissues

MSK II - FOOT and ANKLE (6 decks)

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