Week 2: Management of the foot and ankle (Masterclass) Flashcards by Caitlin O'Farrell

What is the role of a normal tendon? 4 functions…

Connect muscle to bone
Produce joint movement
Maintain joint position
Optimise distance between the muscle belly and joint

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What is the largest tendon in the body?

The achilles

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What is tendinopathy?
How does this pain typically present?
What is the exception?
What provokes tendinopathy?

Refers to pain in the tendon
Typically well-localised
Exception: glute med/min and R/C tendinopathy
Loading (more load = pain)

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Describe the pain response to activity in a tendinopathy…

Latency period/warms up/worse 24 hours after

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True or False: in a tendinopathy no load = no pain

True
- Exceptions: reactive, metabolic, seronegative

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Describe the structure of a healthy tendon?

Highly organised, made up of collagen fibrils embedded in a matrix of proteoglycans

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In a healthy tendon, collagen is enveloped by…What is the substance mainly comprised of?

Ground substance that is mainly comprised of small proteoglycans with hydrophilic glycoaminoglycan chains, supplied by sparse neurovascular structures

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End stage tendinopathy shows…

Minimal inflammation as the underlying pathology is degenerative

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Tendinopathy shows a disorganised appearance of what? What is this described as

Disrupted collagen (disorganised appearance)
Described as mucoid degeneration

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Pathophysiology of tendinopathy
*….. nuclei, ….. tenocytes
* …… ground substance
* Ingrowth of …..
* ….. vessels

Rounded nuclei, fewer tenocytes
Increased
Nerves
Prominent

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Summarise how a healthy tendon would vary to a reactive and degenerative tendon?

Healthy: organised fibres

Reactive tendinopathy: fibers appear slightly disorganised

Degenerative tendinopathy - characterized by highly disorganized fibers (areas of cell death where load cannot be transmitted (middle-older age)

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Risk factor/causes of tendinopathy - examples of this…

Mismatch in load vs capacity (too much for tendon to handle)

Examples Training overloads: single high intensity session, increased frequency of training, different drills, high loads when fatigued, change in footwear, change in surface, training with muscle stiffness

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indications of achilles tendiniopathy

Insidious start
Localised pain
Increase in training volume

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What PROM can be used for achilles tendinopathy? What is the minimum clinically important difference?

VISA-A
- Scored out of 100 made specificall
- MCID of 12 points

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VISA - mean score in non-surgical, pre-surgical and asymptomatic?

Non-surgical = 64/100
Pre-surgical = 44/100
Asymptomatic = 96/100

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What outcome measures could you use to assess someone with achilles tendinopathy?

Patient specific functional scale (PSFS)
Strength measure
Numerical pain rating scale (worst level in the last week/10)

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What type of exercise did Stanish & Curwin propose for AT rehab?

Eccentric-concentric & power
Progression: speed then power
Pain: enough load to be painful in the third set

What type of exercise did Silbernagel propose for AT rehab?

Eccentric-concentric & (Faster E/C), balance & plyo exercise
Progression: Volume/type
Pain: acceptable if within defined limits

What type of exercise did HSR propose for AT rehab?

Eccentric-concentric
Progression: load
Pain: acceptable if not worse after exercising

What type of exercise did Alfredson propose for AT rehab?

Eccentric
Progression: load
Pain: enough load to achieve up to moderate pain

What is the most superior training approach for achilles tendinopathy?

Heavy eccentric calf training may be inferior to heavy slow resistance training (ie both concentric & eccentric is important!)

Heavy slow loading vs eccentric only?

Both strategies improve …. and …. (Murphy MC, 2019)
…… difference b/w VISA-A scores
Traditional eccentric program (Alfredson’s) more …. consuming (300 + mins per week) - compliance?
Little scientific evidence for isolating the ….. component - why not do both?
Magnitude load effects …. …… – not contraction type
HSL – better ….., but requires gym equipment

Pain & function
Little
Time
Eccentric
Tendon adaptation
Compliance

Advice and eduction for achilles tendinopathy?

Activity modification is essential (relative rest/modify activity)
Pain monitoring (traffic light system - pain levels up to 5/10)
No residual pain within 24hrs
No exacerbation after
How much and for how long is guided by irritability

Evidence exists that continuing running with acceptable levels of pain (……/10) in the presence on Achilles tendinopathy does not adversely effect outcome.

<5/10

Effect of exercise on protein degradation vs protein synthesis. First 24-36 hrs? 36-72hrs? Repeated training period with little rest?

* Over first 24-36 hours net loss of collagen --> they require recovery avoid super high loads with low recovery * Net synthesis 36-72 hours post exercises * Repeated training periods with rest that is too short can result in net degradation and lead to overuse injury

Manual therapy for achilles tendinopathy?

* Not very effective for patients with tendinopathy * Avoid any manual therapy directly over the tendon (eg dry needling) * Little use/efficacy - Likely short-term effect for pain for soft tissue massage to triceps surae (group of calf muscles)

What are the four stages of exercise in rehabilitation of achilles tendinopathy

Phase 1: isometrics Phase 2: strength/hypertrophy Phase 3: power Phase 4: sport specific and return to sport *In the return to sport phase remove all stage 3 exercises and replace directly with stage 4. When they are starting to run again no extra plyometrics!

What is insertional AT?

* Pain/tenderness at the tendon insertion (as opposed to midportion – little bit lower down and right at the attachment) * Should be treated separately to non-insertional – respond differently to treatment * Less common – ~25% cases

Insertional AT * Underside of the insertion is compressed against the bony part of the ....... in ...... (walking up a set of stairs or barefoot is provocative) --> key modification = reducing dorsiflexion eg w/...... ....... AND avoid achilles tendon loading with a ....... (as this would place the foot into dorsiflexion)

Calcaneous Dorsiflexion Heel inserts Step

True or False there is to be NO STRETCHING for insertional AT?

TRUE

Ankle sprain: - Group 1: Early PT (PRICE, ROM, weight-bearing, stretching, strengthening, proprioception) - Group 2: Usual care (assessment and instructions for self-management [PRICE, graduated activity] What was the outcome?

* No difference for primary outcome (FAOS ≥ 450 [excellent recovery] at any time point( 1, 3 6 months)

Lateral ligament injury & braces * Study looked at whether functional support (ie ankle brace) helps prevent further sprains - what were the results?

* 1st time sprains: functional support (brace)= effective, exercise = not effective * Recurrent sprain: exercise & functional support (brace) was effective.

When managing lateral ankle injuries what are the stages?

1. Decrease pain and swelling 2. Increase ROM, strength, weight bearing 3. Strength/proprioception training

Education and advice for ankle sprain * Discuss prognosis - clinical course - First episode; benign problem, don’t worry too much - Sometimes, it takes ...... (25%-50% > ..... months) * Risk of CAI (Chronic ankle instability) - Advice to stay ..... - Avoid ...... - Introduce movement ..... * Discuss goals & management options * Graded exposure to movement in .....

Time (25-50% > 3months) Stay active Avoid immobilisation Introduce movement ASAP ADLS

Stability of the loaded ankle (Stormont et al) * Looked at a loading device and how stable the ankle was when loaded in different positions (Stormont et al) What did this study find? What are the implications?

* Found ankle is very stable if you load it in the very centre without any ligaments (must less stable in other positions) * Teach them to distribute wait through the ankle in the centre

Plantar pressure during running in subjects with chronic ankle instability (Morrison et al.,2010) Looked at plantar pressure when running straight forwards in patients who had sprained ankle once vs CAI (multiple sprains) vs controls (never sprained) What were the two main findings?

* Found people who continue to keep spraining their ankle (CAI) vs people who just sprain once or had never sprained (controlled) land differently at heel strike (more laterally) * Also found their centre of pressure (where they are moving towards) during normal gait is substantially more lateral

Clinical implications in CAI (chronic ankle instability)?

* Inability to accurately place the foot * Tend to land more laterally Extra note: Encourage to shift centre of pressure medially as required (“Push through centre of foot or push through your big toe”) when performing exercises (use mirror or band that will pull them more laterally to get them to self-correct)

What element must we not forget to include in ankle rehabilitation?

* Increase cognitive involvement (Thinking when performing a task) * Paramount that we increase cognitive demands to mimic challenges in sport/life (e.g. multi-tasking) eg a rugby player catching a ball whilst doing some ankle plyos

What are the general return to sport timelines? - Simple injuries? - Partial or total rupture of ligaments? - Post-surgery?

* Simple injuries: 3-4 weeks * Partial or total rupture of ligaments: 6-8 weeks * Post-surgery: 12-16 weeks

Manual therapy for ankle sprains? - Is it helpful? - What ROM is vital? - Benefit for DF/pain?

- Can be quite helpful following an ankle sprain - Dorsiflexion ROM key - Adjunct treatment, little (but existent) benefit for dorsiflexion ROM (5.2 deg (95% CI 5.1 to 5.2)); questionable benefit for pain