Week 4 [not including lab] Flashcards
Define: Achilles tendinitis
Define: Achilles tenosynovitis
Define: Achilles tendinosis
Define: Achilles tendinitis: acute inflammatory condition that involves Achilles tendon
Define: Achilles tenosynovitis: inflammation of Achilles tendon sheath
Define: Achilles tendinosis: collagen fibers of tendon degeneration, scarring, and disorganization (no inflammation)
- causes fibrosis and scaring that restrict the Achilles tendon’s motion within the sheath
Etiology of Achilles tendinopathy (3)
- Overloading of tendon during repetitive motions such as running or jumping
- Usually occurs when doing too much too soon with insufficient recovery time
- Decreased gastrocnemius and soleus complex flexibility can also increase symptoms
Achilles tendinopathy symptoms and signs
- generalized pain and stiffness about the Achilles tendon region (just proximal to calcaneal insertion)
- Uphill running aggravates condition
- Reduced gastrocnemius and soleus flexibility (weakness with resisted plantar flexion like toe raises)
- Morning stiffness and discomfort with walking after long periods of sitting
- Tendon may be warm and painful to palpation
- Tendon may appear thickened
- Crepitus when palpated with active plantar flexion and dorsiflexion
- Pain elicited with passive stretching
Achilles tendinopathy management
- Proper footwear and orthotics
- Icing to reduce pain and inflammation
- Ultrasound to facilitate an increased blood flow to the tendon in the later stages of rehabilitation
- Eccentric loading program
- Cross friction massage (breaks down adhesions that may form from healing response and further improve gliding ability of the paratenon)
- Strengthening of the gastrocnemius and soleus
Define: Medial tibial stress syndrome (MTSS)
aka shin splints, pain in the anterior part of the shin
What % of running injuries and what percent of all conditions that cause pain in athlete’s legs are MTSS?
- 10-15%
- 60%
Etiology and factors that contribute to MTSS
- Repetitive microtrauma common in running and jumping activities
- periostitis, strains, cortical bone microfractures
Factors:
- Weakening of leg muscles
- Shoes with improper support or cushioning
- Training errors (running on hard surfaces and overtraining)
- Misalignment problems (varus foot, tight heel cord, hypermobile pronated foot, forefoot supination)
- obesity
- heredity
What are the 2 syndromes that MTSS involves?
MTSS involves 1 or 2 syndromes:
- Tibial stress fracture
- Overuse syndrome (can progress to irreversible exertional compartment syndrome)
MTSS signs and grades of severity
- pain and tenderness
4 grades of pain
Grade 1: pain after activity
Grade 2: pain before and after activity
Grade 3: pain before, during, and after activity (affects performance)
Grade 4: debilitating pain (activity is now impossible)
MTSS management
- Modify activity immediately
- NSAIDS
- Address abnormal pronation (rehab, proper footwear, orthotics)
- Ice massage
- Flexibility program for gastrocnemius and soleus
- Taping
Define: periosteum
a dense layer of vascular connective tissue enveloping the bones except at the surfaces of the joints.
Describe the 2 layers of the periosteum
outer fibrous layer:
- contains blood vessels, nerves, lymphatic vessels that nourish bone.
- Contains sharpey’s fibres that attach periosteum to bone AND ligaments and muscle tendons to bone
inner cellular layer:
- responsible for bone repair and growth, contains osteoblasts which lay down new bone cells as bones grow or repair when damaged
Define:
- osteocyte
- osteoblast
- osteogenic cell
- osteoclast
- osteocyte: maintains bone tissue
- osteoblast: forms bone matrix
- osteogenic cell: stem cell
- osteoclast: breaks down bone tissue
Fill in the blank: the anterior and posterior deep section of the lower leg is separated by the _____________
interosseous membrane
List everything in the anterior compartment of the leg (5)
- tibialis anterior
- EHL
- EDL
- deep peroneal nerve
- anterior tibial artery
List everything in the superficial posterior compartment of the leg (2)
- gastrocnemius
- soleus
List everything in the deep posterior compartment of the leg (5)
- tibialis posterior
- FHL
- FDL
- tibial nerve
- posterior tibial artery
List everything in the lateral peroneus compartment of the leg (3)
- peroneus longus
- peroneus brevis
- superficial branch of peroneal nerve
Lower leg strain
- Ssx
- Tx
- Hx: most common at the gastrocnemius/soleus musculotendinous junction or medial soleus/ tibialis posterior/ FDL muscle belly
- Ssx: pain, tenderness, step deformity, bruising, limp, snap with 2nd or 3rd degree injury
- Tx: P.O.L.I.C.E., taping, physio, ROM exercises, rehab
What is the importance of the tendon sheath
sheath prevents tendon from being pressed upon by surrounding soft tissues or causing frictional issues
Define: peritendon
sheath that covers the achilles tendon
Give the names of the 2 layers that make up the peritendon
- paratenon
- epitenon
State the importance of an eccentric loading program for achilles tendinopathy; give an exercise example
- decreases pain and helps to transition the collagen from weak type 3 to strong type 1 while stimulating the collagen to lay down in a linear pattern
exercise example
1) Assisted raising onto both feet
2) Weight transferred to injured leg
3) Non-assisted lowering
4) Starting with 1 set of 10 reps, increasing to 3 to 5 sets of 10 reps
What are some differential diagnoses of exercise induced lower leg pain.
- medial tibial stress syndrome
- stress fracture
- chronic exertion anterior compartment syndrome
Contributing factors of exercise induced lower leg pain.
- Poor running mechanics
- Inappropriate footwear
- Foot shape and biomechanics
- Lower limb structural abnormalities
- Muscle tightness and imbalance
- Poor conditioning/overweight
- Inadequate warm-up and training errors • Terrain and training surfaces
Describe the stress overload cycle (7)
- muscle fatigue
- loss of shock absorption
- structural stress to bone
- remodeling process
- pain
- voluntary or involuntary disuse
- muscle inhibition/atrophy
- repeat
When an illness has syndrome at the end of the name, what does it mean?
several causes
Tibial stress fractures
- Hx
- Ssx
- DDx
- Tx
- Hx: overuse (running, jumping)
- Ssx: aching pain that is worse with exercise, tenderness with palpitation, x-ray positive (may not show up initially), bone scan positive
- DDx: shin splints
- Tx: adequate rest, walking boot or cast or only light activity, correcting etiologic factors, alternate program of fitness, slow return to activity as tolerated
What does it mean when a bone scan is sensitive but not specific
bone scans show osteoblastic activity
- very sensitive: will pick up anything wrong with the bone
- not specific: will not tell us whats wrong with the bone
What does it mean when the concept of a stress fracture is a healing failure continuum?
bone fracture continuum
- Normal bone → Stress reaction → Stress Fracture → Full (Acute) Fracture
- osteoclastic activity > osteoblastic activity
Define: ischaemia
an inadequate blood supply to an organ or part of the body, especially the heart muscles.
Define: anterior compartment syndrome
ischaemia of muscles
anterior compartment syndrome causes
- internally cause – increased volume of blood (meaning an increase in pressure) possibly from hemmorhage from fracture, swelling from burns, contusion, tumour
- external cause – decreased blood volume: tight casts, bandage dressing
- Overuse (excessive running)
Give the 5 P’s of compartment syndrome symptoms
- pain: out of proportion for their injury, pain with rest or with passive stretch in suspect compartment
- parasthesias: may be earliest subjective complaint due to increase pressure on nerve in tight compartment
- paralysis: also sign of muscle and nerve dysfunction, difficult to differentiate from muscle guarding as a result of pain
- pallor and pulselessness: implies arterial insufficiency. Once pulses are diminished, the damage has been done.
parasthesias
abnormal sensation of the skin (tingling, pricking, chilling, burning, numbness) with no apparent physical cause.
Chronic Anterior compartment syndrome
- Tx
- Adequate rest!
- Correct predisposing factors
- Physician to assess and monitor
- Physiotherapy
- Slow return to activity as tolerate
What is the danger with acute compartmental syndrome and acute exertional compartment syndrome and the treatment plan?
- Potential surgical emergency!!!
- without fast treatment, muscle tissue could die and result in loss of limb function
- NPO & transport to M.D. ASAP
- May need fasciotomy
- Then treat otherwise as for chronic
Differentiate between acute and chronic anterior compartment syndrome
- acute = 30mmHg
- chronic (from exercise) = >30mmHg 1 min after they stop exercise, >25 mmHg 5 min after they stop exercising
Acute lower leg fractures
- Hx
- Ssx
- Tx
- Hx: kick, fall, or ankle sprain
- Ssx: pain, tenderness, bruising, swelling, crepitus, deformity
- Tx: recognize, stabilize, transport to hospital
