Week 5 Flashcards
Identify the main types of ankle sprains and their common presentations.
Grades 1-3. Lateral ankle sprains: Most common, PF&IV, progression of severity from ATFL to CFL to PTFL. Anterior Drawer tests ATFL, Talar Tilt tests CFL. Medial ankle sprains: Injury to Strong deltoid ligaments, they are more severe, medial malleolar fracture. Less common due to decreased eversion ROM and bones. Syndesmotic “high” ankle sprains: Injury to anterior tibio-fib ligament and/or syndesmosis, hyper dorsiflexion, rotation and PF, special tests include syndesmotic squeeze, ER stress test.
Understand the management strategies for acute ankle sprains and interventions that may reduce the likelihood of patients having chronic ankle instability.
Reducing weight bearing does not eliminate pain/edema control, early movement is good thing. Immobilization indicated for grade 3 injury. Thrust and non-thrust techniques may improve pain and function following acute ankle sprain. Therapeutic exercise.
Develop a plan for managing patients that include neuromuscular re-education and an injury prevention program to reduce the recurrence ankle sprains.
Start with proprioception exercises and progress to higher lvl neuromuscular re-education to avoid chronic ankle instability (CAI), braces are recommended for return to sport. Improve closed chain dorsiflexion, if you are lacking you are more susceptible to ankle sprain.
Recognize the risk factors, signs and symptoms associated with plantar heel pain.
Limited DF (need at least 10 degrees to walk normally), high body mass index in non athletes, running due to microtrauma, work-related weight bearing activities. High risk if you are pes cavus & pes planus.
Differentiate these factors and symptoms from other conditions in the region such as fat pad syndrome, tarsal tunnel syndrome, calcaneal stress fractures, or posterior tibial tendinopathies.
Fat Pad Syndrome: reduced cushioning within heel fat pad (more posterior on heel vs plantar fascia), repetitive stress. Tarsal tunnel syndrome: tibial nerve entrapment as it passes deep to flexor retinaculum posterior to medial malleolus, caused by trauma, pes planus, space occupying lesion. Pt will have burning, numbness/tingling, plantar foot paresthesias, positive Tinel’s test. Calcaneal stress fracture: sudden onset of pain, associated with sudden increase in load, repetitive load increase, fall/impact. Pain with weightbearing activities, pain with calcaneal palpation (medial & lateral aspects). Posterior tibial tendinopathies: tendon has 3 major regions of insertion navicular tuberosity, plantar aspect of tarsal bones, base of middle 3 MT. Tender to palpate, pushoff phase of gait will be painful, PF & IV will be affected, more toes exposed on one side vs the other.
Differentiate common physical exam features and tests/measures which distinguish between the primary pathologies affecting the plantar heel region such as plantar fasciitis, fat pad syndrome, tarsal tunnel syndrome, calcaneal stress fractures, or posterior tibial tendinopathies.
Tenderness to palpation at the calcaneus along the medial tubercle(proximal insertion), limited active and passive DF, positive windlass test(great toe), negative tarsal tunnel test, impaired neurodynamics, clear through lumbar spine to rule conditions out, use diagnostic ultrasound 4mm thickening.
Recognize which pathologies are primarily inflammatory and which are rarely inflammatory, truly more degenerative.
Fat pad syndrome: degenerative normally. Tarsal Tunnel syndrome: inflammatory. Calcaneal stress fracture: either one. Posterior tibialis tendon: inflammatory.
Develop a management plan for patients that includes manual therapy for joint and soft tissue mobility, exercise, and offloading for plantar heel pain.
Strong evidence grade A: Manual therapy joints and soft tissue, stretching, taping, night splints. Moderate evidence grade B: resistance training, dry needling.
Recognize red flags related to ankle sprains and heel pain that may warrant further investigation or referral and preclude the use of manual therapy.
Acute ankle pain increasing the pain, severe grade 3 sprain, fractures and syndesmotic injury (Ottawa Ankle Rules), screen for associated injuries.
Describe the research on success with manual therapy and exercise approaches for ankle sprains.
There are 4 predictor variables that if pts have symptoms worse when standing, symptoms worse in the evening, navicular drop > 5 mm, distal tibiofibular joint hypomobility. In the acute phase of the injury use manual therapy for lymph drainage, edema reduction, and decrease of pain. Moving out of the acute phase we can add mobs/manips, functional retraining, strength, proprioception.
Recognize the regional approach used in several of these studies, and that a test retest model should be used to validate intervention choice.
Find a comparable sign that can be measured. This way we can have a pre test post test response to our intervention.
Recognize red flags related to ankle sprains and heel pain that may warrant further investigation or referral and preclude the use of manual therapy.
Acute ankle pain increasing the pain, severe grade 3 sprain, fractures and syndesmotic injury (Ottawa Ankle Rules), screen for associated injuries.
Describe research on success with MT and exercise approaches for plantar heel pain, cuboid syndrome and hallux limitus conditions.
Plantar heel pain: Interventions used that have success are stretching, using impairment based manual therapy(mobs/manip), using custom orthotics, strengthening. Cuboid syndrome: pain during gait and push off, pain over cuboid. Black Snake Heel Whip manipulation to reduce subluxation, manipulations help a lot with cuboid syndrome. Hallux rigidus/limitus: degenerative arthrosis 1st MTP, common big toe injury in athletes. Manipulation techniques can restore ROM and restore gait. Sesamoid mobilization, FHL strengthening, gait training have been shown to help.
Recognize the regional approach used in several of these studies, and that a test retest model should be used to validate intervention choice.
Find a comparable sign that can be measured. This way we can have a pre test post test response to our intervention.
Describe the surgical procedures and post-operative rehab protocols used for patients with Achilles rupture and tarsal tunnel release.
Achilles tendon repair: open or percutaneous. Surgery vs conservative care. Accelerated rehab, protocols vary, operative cases usually 4 weeks ahead of non-operative. Accelerated program heals faster. Earlier weight bearing after surgery and initiation of ROM activities speed up the healing process. Week 6 progressive resistance exercises. Week 7 post op ROM can be progressed as tolerated and can get out of the boot. Recovery of 6-9 months, sports over a year. Tarsal tunnel release: 3 weeks of immobilization non-weight bearing activities, tissue mobility(incision, mobs, gentle nerve glides), progression into DF and start gait training & functional re education. 2 months to return to ADL’s.
