The leg and foot Flashcards
Medial tibial stress syndrome - What is it?
Periostitis (inflammation of the band of tissues that surrounds the periosteum) of medial margin of tibia, although no unanimity of opinion regarding definition. Exertional lower leg pain posteromedial tibial border. Linear, not focal.
What is medial tibial stress syndrome often wrongly referred to as…
‘Shin splints’
Shin splints is an umbrella term including compartment syndrome , stress fractures, muscle hernia, tendon strain.
Clinical features of medial tibial stress syndrome
Pain on loading (usually running, climbing etc) distal medial
margin tibia. Eases with rest. Often assoc with change in work/athletic routine, type/volume activity, footwear etc.
Usually full painless ROM all joints. Resisted movements usually
painless. Possible pain on repeated hopping or, if severe, repeated p.flexion + inversion.
Often ↑ pronation. Tenderness+ along distal medial tibia.
Possible minor swelling in medial compartment.
X-Rays will be negative. MRI Ix of choice.
Medial tibial stress syndrome- treatment
Stop aggravating activity to prevent chronicity
If athlete, can maintain fitness using non-WB, non-impact activtiy
Crucuial to identify precipitative factor(s) + address accoridngly. May include:
Compressive strapping
Stretching + Strengthening, possible mobilisations
Orthotics
Activity modification and gradual return
NSAIDs, acupuncture, ice etc
Stress fracture - lower limb
What is it
repetitive/excessive stress on bone → accl normal
bone remodeling → microfractures due to insufficient time for
bone to repair → bone stress injury → stress #.
% of sporting injuries- stress fractures lower limb
10% (Robertson and Wood, 2017)
Stress fracture - Lower limb
Tibia –75% of all stress #’s. Prox to mid-point. Can occur
anterior or posteromedial diaphysis
Fibula –usually distal third
Navicular
2nd -4thmetatarsals (usually 2nd)
5thmetatarsal –base
Sesamoids –great toe
Can also occur medial malleolus and calcaneus
Ant tibial, navicular, med malleolus, 5thMT + sesamoids are
‘high-risk’ as ↑ chance → to full fracture and/or non-union
Stress fracture - lower limb (Clinical features)
Pain localised over # site on activity, nearly always WB/impact
Usually assocwith a change in activity egvolume/nature
Often deep ache, initially eases with rest, but steadily ↑ to
include night pain + resting pain
May be assocwith problems with bone health eg↓ vit D, ↓ calcium, eating disorders, osteoporosis.
More common in females, espabnormal/absent menstruation
Exam often unremarkable. Posstenderness over # site on
percussion. Also single leg hopping + tuning fork. However, no single test of proven reliability
X-Rays commonly clear, espin first 4-8wks. MRI Ix of choice
Stress fracture- lower limb treatment
Physiotherapist’s primary job is to diagnose
History + knowledge of common stress # sites will raise level of suspicion
REST, REST, REST from causative activity. This may include splinting, boot, POP, NWB or simple activity
modification
Maintain fitness whilst fracture healing
Rehabilitation when fracture healed → graded rtnto activity
May need to assess progress with imaging
Surgery if # does not heal. Much more common in high risk
stress #’s
Ankle sprain- what is it?
Tearing of ankle lgts/capsule due to excessive force.
GrI = microtearing, grossly intact; GrII = incomplete tear; GrIII =
rupture
Inversion sprains
most common (85% of all ankle sprains) + often cited as most common sports injury. Ligaments injured =
ant talofibular lgt (ATFL) → calcaneofibular lgt (CFL) →
calcaneocuboid lgt (CCL) → post talofibular lgt (PTFL)
High ankle sprains
1-11%
- distal tib/fib syndesmosis is
damaged, (dorsiflexion/external rotation force)
Eversion sprains
strong + extensive deltoid lgt is
damaged. Often this leads to bony avulsion
Intra-articular damage - ankle sprains
Can occur + is frequently missed, with serious repercussions for the pt eg osteochondral damage, talar
dome #
Ankle sprain - clinical features
Sudden traumatic onset
Pain, swelling, bruising, possible instability
What must you check for with ankle sprain
Effusion –swelling post jteither side of Achilles. A missed
effusion, and, therefore, a missed intra-articular lesion in an
ankle, which is then treated as a conventional lat lgtsprain, is
one of the most common, avoidable causes of patients having
to retire from sport/activities
Lgttear/instability –inversion +/-pflexion(ATFL), dflexion
(CFL); drawer test, palpation
Deltoid lgtavulsion
High ankle sprain tests –dflexion+ extrotation, squeeze test
Talardome #, osteochondral lesion –punch test
May need X-Rays and/or MRI
Beware persistent/disproportionate pain in a seemingly mild
ankle sprain
Ankle effusion
X-Ray showing classic
teardrop shape to anterior
ankle effusion. However, it
is the posterior aspect of
the effusion that is normally
easiest to detect clinically,
although it tends to be less
defined radiographically.
Ankle sprain - treatment
Crucial to diagnose nature and severity of injury as accurately as possible, although often have to wait until acute phase has settled.
Acute phase- rid swelling/effusion, protect lgts from further damage + maintain movt in pain free range - PRICE, strapping, splinting, rehab, possible boot/POP
Rehab phase- mobilisation of foot/ankle jts, strapping, progreeive rehab to address strength + proprioception. Gradually progress to include WB + impact type exercises, depending upon pt’s objectives.
May need strapping/splinting on return to sport.
Persistent pain after ankle sprain…
Needs to be reviewed and if not investigated.
Osteochondral lesions, talar dome fractures, navicular fractures with possible subsequent AVN, avuslion fractures and syndesmosis disruption/instability are all frequently missed.
What is plantar fasciitis
Inflammation of the plantar fascia, usually
medial calcaneal tubercle, due to repetitive, excessive,
unaccustomed or prolonged stress
Plantar fasciitis
Pain under heel on rising, prolonged walking or standing. Often eases initially with exercise
Also aggravated by walking uphill + unsupportive/worn shoes
May have restricted calf or ankle or foot, esp mid
tarsal joint. Particularly linked with hyperpronation + pes planus
Associated with obesity, standing jobs, high impact
sports
Plantar fasciitis treatment
Identify aggravating/precipitative factor(s) and address.
This could include footwear, weight, ergonomics, posture, leisure/sporting activities
NSAIDs, ice
Stretches/soft tissue work to calf/fascia
Mobilisations to ankle, foot
Strapping
Heel pads and/or orthotics
Injection
Dry needling
Shockwave
Orthotics
Based on the theory that small alterations in the biomechanics of the foot/ankle will have a ‘knock-on
effect’ up the lower limb and beyond.
Thus, biomechanical anomalies in the lower limb can cause an array of lower limb/back problems, ranging
from sciatica to plantar fasciitis.
These anomalies may be congenital, developed or
acquired.
An orthotic purports to correct these biomechanical
anomalies.
Orthotics solution:
History, history, history
Look for changes –activities, lifestyle, footwear,
disease profile, imaging.
The default position should be to use orthotics as a last resort, unless there are very persuasive clinical
arguments to the contrary
Can use them as a temporary measure much more
frequently
Always follow up the patient
