Week 2 - Common foot and ankle conditions, problem ankle, sports podiatrist

Question 1

‘What ligaments are damaged in a lateral ankle sprain?

Answer 1

anterior talofibular (ATFL), the calcaneofibular (CFL), and posterior talofibular (PTFL)

ATFL most commonly injured

Question 2

What should be involved in initial management of lateral ankle sprain (Ottawa)

Answer 2

Ottawa rules xray ie can they weight bear, tenderness to palpation lateral melleolus, tenderness mid food tarsals (Jenkin et al., 2010)

POLICE

Question 3

What should be considered in children lateral/inversion ankle sprains

Answer 3

Consider avulsion (weaker bones)
Consider growth plate (salter harris)

Question 4

Predisposing factors to lateral ankle sprain

Answer 4

Vuurberg et al (2018)
Intrinsic: reduced dorsiflexion ROM, reduced proprioception, poor balance, high medial plantar pressures during running, lower BMI, females, increased height

Extrinsic: type of sport eg basket ball, volleyball, climbing, field sports, within sports eg landing after a jump, grass versus turf, shoe wear

Inversion accounts for 70-80% (when foot is plantar flexed and inverted)

Question 5

Diagnosis of lateral ankle sprain

Answer 5

Vuurberg et al (2018)
Exclude fracture using Ottawa rules (within 1 week),
Classify into grade relating to severity
If haematoma around distal fibula, likely rupture
Anterior draw test sensitive 4-5 days post injury
US - high similar sensitivity, lacks specificity
MRI - high sensitivity, high specificity

Question 6

Management of lateral ankle sprain

Answer 6

POLICE
Vuurberg et al (2018)
Ice not good evidence, compression inconclusive, no evidence for rest and elevation –> no rule for RICE
NSAIDs can be used but may be associated with complications/supress healing process
Functional support for 4-6 weeks (if symptoms still unresolved at this point consider MRI for osteochondral damage)
Exercise as able
Manual joint mobilisation advised
Surgery if needed for individual/sport - required for distal AIFTL rupture with widening of ankle mortise

Question 7

Prevention of lateral ankle sprain

Answer 7

Brace and tape have a role
Exercise therapy ASAP following, not necessarily preventative for first time
No clear footwear recommendations

Systematic review looking at balance injury prevention programmes – showed a decrease in ankle injuries in football players.

Question 8

Discuss medial ankle sprains

Answer 8

Less common than ATFL
Medial (deltoid) ligament is a strong ligament so big force to damage it therefore longer rehab time
Consider footwear (rehab time longer esp if foot over pronates excessively)
Eversion injury commonly external rotation of tibia with foot planted
Stronger than lateral so more commonly accompanied by additional injuries including fractures therefore radiographs indicated and widening of ankle mortise may require surgery
Similar rehab to lateral but much longer recovery

Question 9

Types of tendiopathy in foot/ankle

Answer 9

Tendinopathies
What is the pathology of a tendinopathy?
Common tendinopathies at the ankle and foot:
Peroneal
Tibialis posterior
Tibialis anterior
Achilles
What S&S may you suspect with this tendinopathy - consider the action of this tendon?
Devise a graduated isometric/isotonic/plyometric exercise programme

Question 10

Discuss MOI, S+S, assessment and management of plantar fasciitis (Latt et al 2020)

Answer 10

Chronic overuse injury from repetitive traction on the plantar fascia attachment to the medial calcanea tuberosity.

(Latt et al 2020)

Stiff +++ in the morning
Slow recovery - frequently aggravated

MOI - Often found in individuals with over-pronation, initialled by wearing sandals or soft shoes

Risk factors/aetiology - intrinsic (over pronation, leg length discrepancy, overweight, gastronemius tightness), extrinsic (overuse, incorrect training load)

S&S - heel/plantar pain. Often pain at the painter fascia attachment to calcaneus antero-medially

Assessment - examination, radiographs not needed as vast majority normal (Latt et al., 2020), ultrasonography useful for both diagnosis and monitoring of treatment (Latt et al., 2020)

Management/prevention –
Initial management – NSAIDs, activity modification, plantar fascia stretching, gastro stretching and use of heel lift, arch support or night splint effective for most (Latt et al., 2020)
(Latt et al., 2020):

Corticosteroid injection – temporary relief but associated with increased risk of persistent pain, local tissue atrophy and rupture

Botox – poor evidence support

Platelet rich plasma – more evidence

Shockwave therapy – sort term pain relief and functional outcomes but long term outcomes not yet known

Operative – indicated when pain and functional limitiations persist despite non op trial lasting at least 6 months. No consensus on operative technique.

Question 11

Discuss medial tibial stress syndrome

Answer 11

Literature can be confusing for this one..

Pain along the postero medial border of the tibia that occurs due to exercise, over 5 or more consectuvie centimetres (Winters et al., 2013).

It occurs when the tendon of the tibialis posterior is over-worked resulting in a traction of the fascial connection with the periosteum of the bone. The fascvial structures become restrictive rather than there being actual damage to the bone.

Predisposing factors multifactorial (Becker et al 2018). Fewer eyars running experience, orthotic use, increased BMI, increased navicular drop, female gender, previous history of MTSS (Newman et al., 2013)

MOI - Gradual onset, repetitive loading in running, training errors, biomechanics

Signs and symptoms - Diffuse pain medial third tibia (more focal/night pain may be stress fracture), worse at the start of training, improves during then worse afterwards and the next morning. (Winters et al, 2017)

Management:
Low impact/rest/crosstraining/load management
Taping to control foot pronation
Orthotics/biomechanical assessment/shoes
Acupuncture
Soft tissue massage
Stretching
Eccentric strengthening (esp ankle invertors, dorsiflexors and toe flexors) - observe for overuse EHL and EDL

Question 12

What is the gribble et al 2022 paper

Answer 12

Those thin history of ankle sprain have clinically meaningful differences in BMI, pain, PA and health related QoL compared to those that have not. Suggests association between ankle sprain history and general health.

Question 13

What is chronic ankle instability (CAI)

Answer 13

Repetitive bouts of lateral ankle instability resulting in numerous ankle sprains (Hiller et al 2011)

Question 14

Functional/mechanical causes of CAI

Answer 14

Functional:
* Reduced proprioception
* Reduced neuromuscular control
* Poor postural control
* Impaired strength

Mechanical
* Pathological laxity - grade 3
* Impingements - loose bodies; osteophytes; chronic synovitis
* Osteochondral damage
* Degenerative changes

Question 15

Assessment of CAI

Answer 15

• Cumberland Ankle Instability Tool (CAIT) - valid and reliable questionnaire (Hiller et al, 2011)
• Star excursion balance test (SEBT) - assesses postural control/strength/ROM (Gribble et al 2012)
  Functional and mechanical instability
  Mechanical instability
• Pain on dorsiflexion during weight bearing
• Anterior drawer test - high intra rater reliability (Hiller et al 2011)
• Imaging - real time USS, MRI, CT

Question 16

Signs/symptoms of CAI

Answer 16

(Tanaka and Masson 2011)

Feelings of instability
Giving way
Recurrent ankle sprains

+/- pain on dorsiflexion
Weakness and lack of proprioception
Anterior drawer

Question 17

Management of CAI (functional/mechanical)

Answer 17

= address functional insufficiences - rehab (comprehensive/intensive rehabilitation program must continue weeks to months after intial symptoms have subsided) (Kosik et al 2017)
Exercise therapy – high evidence
Manual therapy – high evidence
Bracing – effective at preventing a recurrence
Taping – Inconclusive. Some studies find it effective and others find bracing better
Modified footwear – inconclusive
Orthotics – lack of evidence
(Doherty et al 2017)

= address mechanical insufficiencies
Pathological laxity - grade 3 injury
Grade 3 lateral ligament injuries that fail rehabilitation, or if sport specificity requires the athlete to have more support eg gymnastics, diving:
Tendon reconstruction (using peroneus brevis)
Brostrom procedure - the ligament is repaired
Use of free autograft or allograft tendon
(But most grade 3s can be fully rehabed!)

Question 18

S+S/Management of loose bodies

Answer 18

Pain during dorsiflexion when weight bearing
Locking

Cons: Accessory mobilisation/orthotics/avoid excessive DF/strengthening and proprioceptive exercises

Surgical: Arthroscopy may be required following unsuccessful conservative management

Question 19

MOI/S+S/Management of osteophytes (anterior impingement)

Answer 19

Related ankle DF
Degenerative changes

Pain during dorsiflexion when weight bearing

Cons: Accessory mobilisations/orthotics/avoid excessive DF/strengthening and proprioceptive exercises

Question 20

MOI/S+S/Management of os trigonum (posterior impingement)

Answer 20

Os trigonum is an extra bone at the back of the heel. Impingement of it or posterior talus can occur from forced plantar flexion of the ankle. This produces a pain posterior to ankle joint deep to achilles.

Occurs following a lateral ankle sprain

Pain during plantar flexion

Management :
Accessory mobilisations,
orthotics,
avoid excessive PF,
strengthening and
proprioceptive exercises

Corticosteroid injection

Surgical management - removal of posterior spur/os trigonometry

Question 21

MOI/S+S/Management of chronic synovitis (chronic inflammation the synovial tissue)

Answer 21

Following CAI
Too aggressive rehab or RTS too early

Anterior pain during dorsiflexion when weight bearing

Management:
Appropriate rehabilitation,
strengthening and
proprioception exercises

US guided corticosteroid injection

Question 22

MOI/S+S/Management of osteochondral injuries

Answer 22

Common after ankle sprains - when the sprain damages the cartilage of the talus
Jumping from a height or high speed running

Usually diangosed late following persistent pain, stiffness and locking

Treatment depends on grade - conservative versus operative

CT or MRI for diagnosis, therefore often no picked up as these not undertaken

Question 23

Whats the long term prognosis for a poorly rehabilitated ankle?

Answer 23

Fear avoidance
Disengagement with PA/sport
Weight gain
Poor physical and mental health
OA
(Delco 2017), (Paget et al 2020)

Question 24

Ankle/foot assessment

Answer 24

Inspection of three ankle joints - talocrural, inferior tibiofibular joint and subtalar. Assess for neutral/pronation/supination. Evidence of abnormal biomechanics.

Palpation - Of joints, based with metatarsal etc (think about it)

Active/passive movement:
Dorsiflexion, plantar flexion, subtler inversion, subtalar eversion

Special tests:
Ankle sprain grades 1 - pintail without instability, mild instability, rupture
Anterior draw (injury to the ATFL)
Squeeze test

Functional tests:
Squat, heel raise, hop etc

Standing assessment - weight bearing, proprioception, biomechanics, functional tests, flexibility, DF in standing

Assessment on plinth - active and passive ROM, palpation, resisted muscle tests, anterior drawer test, accessory movements

Question 25

Rehabilitation of ankle/foot injury

Answer 25

Eg of ankle sprain

Early days - minimises swelling, maintain ROM, OL, isometric strengthening, challenge balance
Eg alphabet exercises help kinaesthetic awareness

Middle stage: Enhance neuromuscular control, increase strength ROM ankle mobility, initiate weight bearing exercise.
Eg single leg standing
Athlete balances on injured leg while throwing and catching ball
Strength - foot/ankle weights or therabands, heel to toes, since leg heels to toe +/- upper body support, walking on heels toes
Progress - mini squats, drop squats, single leg squats, lunges
Cardiovascular

End stage:
To progress muscle have full ROM and good baseline of stretch throughout all movement. Progress to eg squat, deadlift,
Plyometric exercise - 2 legs to one leg, hop scotch, jumping vertically while rotating
Straight line running, progressive running
Functional running exercises
Field testing if available eg vertical jump, sprint times, standing broad jump distance

• Reduce pain and swelling
• Restore ROM
• Muscle strengthening
• Proprioception
• Functional rehabilitation
• Return to sport
• Injury prevention
  (Rodriquez-Merchan (2012)

Things affecting healing –> Maestronie et al 2020 eg general health societal factors, psychological factors, MSK system

Question 26

Proprioception during rehab of foot/ankle injury

Answer 26

Verhagen et al 2004 - Proprioception describes nerve (mechanoreceptor) impulses originating from the joints, muscles, tendons and associated deep tissues, which are then processed in the central nervous system to provide information about joint position, motion, vibration and pressure.

Begin proprioceptive and balance traiing as early as possible

Question 27

Role of the podiatrist

Answer 27

Sports podiatrist -> assessing injured athlete, involved in injury prevention, protection of injury, performance enhancement, biomechanical analysis

Biomechanics - draw heavily on engineering principles.
There is a point at which material will fail under a given force
Alter speed (acceleration/deceleration) and/or direction of force - altered effect on vulnerable injured structure (Youngs Modulus of Elasticity). All structures have a yield point.

Things to consider - type of shoe, playing surfaces, level of participation, changes in training programs, know demands of sepcific sport

Static weight bearing assessment - head to toe assessment (Chuter er al 2012), simplified foot assessment using the foot posture index (Redmond et al 2006)

Question 28

How do podiatrists assess?

Answer 28

Static weight bearing assessment - head to toe assessment (Chuter er al 2012), simplified foot assessment using the foot posture index (Redmond et al 2006)

Supination - calcaneal inversion, talar plantar flexion, adduction
Pronation - calcaneal eversion, talar dorsiflexion, abduction
–> Use foot posture index (Redmond et al 2006)

Dynamic assessment is gait analysis - pre-requisite of good gait.. stability in stance, foot clearance in swing, pre-positioning of the foot, adequate step length, energy conservation

Question 29

Evidence for orthotics

Answer 29

Orthotics give a customised fit, add control, alter timing at specific points, useful in unilateral length discrepancy (LLD), can be made sport specific eg ski boot (Bonanno et al 2016)

Question 30

Evidence for shoes

Answer 30

Minimalist shoes increase the load on the Achilles and increase peak ankle dorsiflexion
Pronated foot type linked with plantar fasciitis and post tib
Minimalist shoes improve running economy and thuse improve perofrmacne due to reduced weight of shoe (Fuller et al 2017). Reduced weight = reduced shock absorption
A low drop (heel to toe hieght) shoe is associated with higher injury rate in frequent runnners (but not accoasional runners) (Malisoux et al ,2015)

Any transition from high to low heel drop should be gradual – comfort very important (Nigg et al 2015)