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Peripheral Musculoskeletal science > Week 6 Lecture > Flashcards

Week 6 Lecture Flashcards

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1
Q

• Describe the functional anatomy and common mechanisms of injury of the ATFL, CFL, PTFL, deltoid ligament and inferior tibiofibular (syndesmosis) ligaments

A

Mechanisms of injury
85% involve supination injury mechanisms
15% consist of pronation/eversion mechanisms

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2
Q

What ligaments make up the lateral ligment of the ankle

A

ATFL- anterior talofibular ligament
PTFL -posterior talofibular ligament
CFL- Calcaneofibular ligament

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3
Q

What ligaments make up the deltoid?

A 
(medial aspect of foot)
Posterior tibiotalar lig (PTTL)
Tibiocalcaneal lig (TCL)
Anterior tibiotalar lig (ATTL)
Tibionavicular lig (TNL)
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4
Q

What ligaments make up the inferior tibiofibular/syndesmosis ligaments?

A

AITFL- Anterior inferior tibiofibular ligament

PITFL- Posterior inferior tibiofibular ligament

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5
Q

Outline the grading system for supination injuries and the relevance of grading these types of injuries

A 
Grade 1
Partial ATFL +- CFL 
well localised mild edema
< 5   decrease in ROM
Less common medial joint bone bruising
FWB with only mild pain
No ligamentous laxity, softer EF
Average time RTS 10-12 days
Grade 2 
Complete ATFL +- partial CFL
Localised moderate edema
>5 decrease in  ROM
More common/marked medial joint bone bruising
FWB with sig pain
Mild-Mod ligamentous laxity, altered endfeel
2-3/52  Return to sport
GRADE 3
Complete ATFL &amp; CFL +- PTFL
Odema > 2 cm
Decreased ROM > 10degrees
Severe medial joint signs (bone bruising)
Intolerant of FWB
Marked ligamentous laxity, Empty end feel
6/52 RTS
Normal stress radiograph
GRADE 4
Complete ATFL &amp; CFL +- PTFL
Odema > 2 cm
Decreased ROM > 10 degrees
Severe medial joint signs (bone bruising)
Intolerant of FWB
Marked ligamentous laxity, Empty end feel
10/52 RTS
Stress radiography >3mm difference

Found that clinical symptoms were not well correlated with the grade of injury.
Amount of swelling and ability to weight bear were the factors most correlated with the severity of bone bruising.

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6
Q

West point classification system for high ankle sprains

A 
GRADE 1
mild-min fibre disruption
mild-min swelling (well localised)
Tolerant of WB on flat ground
Loading to DF is provocative
Min- mild mechanical laxity(abnormal)
GRADE 2
Mod fibre disruption
Mod swelling(well localised)
Less tolerant of WB on flat ground
Marked provocation w loaded dorsiflexion
Moderate Mechanical laxity with pathological end feel

GRADE 3
Severe fibre disruption
Severe swelling, diffuse but remains in high ankle region
Unable to WB due to pain and/or apprehesion
Marked laxity with clear pathological end feel

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7
Q

List common associated injuries and differential diagnoses following acute ankle sprain injuries (4)

A

Avulsion fracture of the base of 5th MT
Osteochondral injuries
Malleolar fractures
Dislocation/subluxation

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8
Q

• Discuss the Ottawa Ankle Rules
when is an ankle series required
when in a foot series required

A

An ankle XR series is required if:
TOP midline distal 6cm of fibula OR of lateral malleolus
TOP midline distal 6cm of tibia OR of medial malleolus
Unable to WB at ]me of the injury and unable to walk 4 steps in the clinic or ED

A foot XR series is required if…
TOP base of 5th metatarsal and/or
TOP at the navicular and/or
Unable to WB at time of the injury and unable to walk 4 steps in the clinic or ED

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9
Q

Why are supination(low ankle) sprains more common?

A

-Size lig support
deltoid thicker & broader than lat lig

-Loose packed position of talocrual joint
landing in PF TC joint is in loose pack position & more dependent on NM support

-Speed on NM response
Rapidity of ankle sprain injury exceeds ability of protective muscle reactions

-size of medial malleolus
MM blocks inversion fo calcaneus & talus less than LM blocks eversion

  • Relative capacity for excursion
    2: 1 ratio of inversionn to eversion
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10
Q

Common mechanism of injury for

LOW ANKLE SPRAINS

A

-Supination
(platarflexion)
(Inversion)
(Adduction)

Lateral ankle complex strains 85%

Structures affected
ATFL
CFL
PTFL

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11
Q

Common mechanisms of injury for

HIGH ANKLE SPRAINS

A

-Pronation aka external rotation of foot
(Dorsiflexion)
(Eversion)
(Abduction)

  • Hyperdorsiflexion(talus forces malleoli apart)

Injury to
Distal Tibifibular joint/syndesmosis
-AITFL(Anterior inferior tibiofibular ligament)
-PITFL(Posterior inferior tibiofibular ligament
-Transverse ligament
-Interosseous ligament

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12
Q

Imaging of inferior tibiofibular joint

Not in objectives so not super important

A

On AP views look for:
-Tibiofibular Clear space(TFCS)
Horozontal distance from lat boarder post tibial malleolus to medial boarder of fibular
(>5 mm abnormal)

-Tibiofibular overlap
Horozontal distance between medial borader of fibula to lateral boarder of ant tibial promenence
(<10 mm abnormal)

On MORTICE veiws look for:
-Medial clear space
Distance b/n lateral aspect of medial malleolus & medial border of talus at level of talar dome.
(>4mm abnormal)

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13
Q

The high ankle sprain

A

• Symptoms
– Focal pain above the ankle joint( radiates superiorly)
– No significant swelling/bruising
- Poor WB tolerance esp if combined with rotational stress or Loading in DF
– Level of pain disability may be disproportionate to the initial perceived severity of the injury

Diagnosis
• Stress tests for injury to the syndesmosis
– The Squeeze test( Sx reproduction induced by a gapping force applied to the mid tibia and fibula)
– External rotation test Kleigers test
– “Cotton” test Lateral shear of talus on a fixed leg

Determines damage to Deltoid lig
AITFL
PITFL
Interosseous membrane

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14
Q

Which muscles casue inversion and eversion of the foot?

A

The muscles which cause inversion of the foot are:
Tibialis anterior
Tibialis posterior
The muscles which cause eversion of the foot are:
Fibularis longus
FIbularis brevis

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15
Q

Supination and pronation are triplanar movements

List the movements that make up each

A

Supination:
Inversion
Plantarflexion
Adduction

Pronation:
Eversion
Dorsiflexion
Abduction

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16
Q

List 3 important joints of the foot and the movements that occur there

A

Talocrual joint: Plantar/dorsiflexion

Subtalar joint(Talocalcaneal) joint: Inversion/eversion

Transverse tarsal joint:Inversion eversion

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17
Q

3 parts of the foot and the bones that make up them

A

HIND FOOT: talus & calcaneus
(STJ)

MIDFOOT: Cuboid, navicular, 3 cuniforms
(Transverse tarsal joint)
Inversion/eversion + plantarflexion/dorsiflexion

FOREFOOT: metatarsals, phalanges

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18
Q

• Discuss the key subjective examination issues following traumatic injury to the ankle and foot

A

History of ankle trauma (chronic reccurent pattern)
Recurrent giving way +/- recurrent ankle sprains (recurrent ankle effusion)
Feelings of instability/howllowness/weakness

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19
Q

• Describe some of the common complications following acute ankle ligament injury which may lead to a delayed recovery and how these complications may be managed

A 
Complications of ankle lig sprains (non acute)
Chronic ankle instability (CAI)
Subluxing peroneal/fibularis tendons
Talar dome fracture
Post-traumatic synovitis
Ankle impingement

Recurring theme here is recovery taking longer than the expected biological healing time-frames for an otherwise uncomplicated ankle sprain

*Perceived instability is the most consistant predictor of disability

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20
Q

• Discuss the reliability, sensitivity and specificity of Functional Outcome Measures (FOMs) (hop tests) following ankle injury

A

Impaired balance/proprioception as measured by relevant FOM (hopping tests)
SEBT( star excursion balance test)
Jump-landing
Side-side hop test
Figure of 8 hop test

High reliability for patients with CAI has also been demonstrated when performed as a cluster of single limb hop tests

SEBT:
-Reliability 0.67 to 0.87

No single test is sufficiently accurate for diagnosis but a combination of symptoms and tests can confirm ankle syndesmosis involvement
• Sensitve
– An inability to hop
– Syndesmosis ligament (AITFL) TOP
– Positive DF external rotation stress test
• Specific
– Pain out of proportion to injury and
– Positve “Squeeze” test

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21
Q

• Describe the common intrinsic (including sub-optimal foot and ankle biomechanics) and extrinsic factors that may lead to the development of tissue injury in the lower leg, ankle and foot region

A

Intrinsic:
Extrinsic:

Medial Tibial Stress Syndrome
– Intrinsic
• Excessive/uncontrolled pronation
• Muscle tightness (PF’s)
– Compensatory overpronation
• Running technique

– Extrinsic
• High and/or unaccustomed training loads
• Hard training surfaces
• Poor footwear (inadequate support)

22
Q

Entrance criteria for functional testing of FAI/CAI

A 
No ankle effusion
Full pain free ankle/STJ ROM
Pain free broad jumps
Pain free hopping on the spot
Normal walking gait
Normal pain free straight line jogging/running gait
23
Q

Common mechanisms for Medial complex sprains

How common are they?

A 
5% of cases
Pronation
(Dorsiflexion)
(Eversion)
(Abduction)
24
Q

Discuss validity and reliability of

ANKLE STABILITY TESTING

A

Reliability & validity LOW in acute phase

Manual stress tests only acceptable:

  • Within 1st hour or
  • 4-7 days after injury
25
Q

What ligaments does the Anterior drawer test

Test?

A

Tests
ATFL(Anterior Talofibular ligment)
Anterior band of deltoid

26
Q

What ligaments does the Talar Tilt test

Test?

A

In Plantargrade:
CFL (Calcaneofibular ligament)

In 20 Plantarflexion
CFL(Calcaneofibular ligament)
ATFL(Anterior talofibular ligament)

In Eversion:
Deltoit
PF for Anterior bands
DF for Posterior bands

27
Q

What ligaments does the Posterior drawer test

Test?

A

PTFL(Posterior talofibular ligament)

28
Q

What do the medial and lateral subtalar glide tests
Test?

ELABORATE ON THIS…

A

Tests medial and lateral ligaments

29
Q

Which 4 landmarks are crossed in a figure 8 to determine the level of odema of the ankle?

A

Navicular tuberosity
Distal tip of lateral malleolus
Distal tip of medial malleolus
Base of 5th metatarsal

30
Q

Define functional ankle instability(FAI)

Define Mechanical instability(MI)

A

Functional ankle instability
Frequent episodes of giving way of affected ankle joint & feelings of instability during function

Mechanical instability

Excessive inversion and or Anterior laxity

+- stress radiography
(Joint ROM exceeds normal physiological & accessory ROM)

31
Q

Define “giving way”

A

Regular occurrence of

UNCONTROLLED ANKLE JOINT INVERSION episodes that do not necessarily result in ankle joint sprain

32
Q

Define chronic ankle instability(CAI)

A

Both mechanical & functional instability where symptoms go giving way and instability have been present for at least 1 Year post

Functional ankle instability
Frequent episodes of giving way of affected ankle joint & feelings of instability during function

Mechanical instability
Excessive inversion and or Anterior laxity
+- stress radiography
(Joint ROM exceeds normal physiological & accessory ROM)

33
Q

Define Mechanical instability

A

Excessive inversion and or ANTERIOR LAXITY

+- stress radiography ( joint ROM exceeds normal physiological & and accessory movement)

34
Q

Acute ankle trauma

Key principles of management

A 
S upport= taping or bracing
P rotect = period of limited load
R est= Limit unnescessary loading in first 24-48 hours
I ce
C ompression
Elevation
Movement  (early and graduated)
Medication 
P rotection
Optimal Loading
I ce 
Compression
Elevation
35
Q

Subluxing peroneal tendons
methods of diagnosis,
clinical presentation (subjective and objective clinical features)
key methods of treatment and management

A

Results from disruption of the superior peroneal retinaculum and usually involves an avulsion of the retinaculum from its fibular insertion

  • MOI typically involves an inversion injury to the dorsiflexed ankle with accompanying forceful contraction of the peroneals
  • Isolated injury is rare (but very possible) and can result in ongoing subluxation and pain– More common in recurrent ankle sprain pathology

S/E
• Symptoms over the posterolateral aspect of the ankle
• Painful ‘locking’ or ‘snapping’ along the lateral ankle
with activity
– Tendons sublux anteriorly with contraction or stretch of fibularis muscles in the lateral compartment

• P/E
– Fx tests (Pain with toe walking)
– TOP and swelling are noted over the posterolateral aspect of the ankle and distal leg
– Resisted tests
• Reproduction of pain and subluxation
• Weakness of ankle eversion
• Dx commonly confirmed with US, CT and/ or MR

• Subluxation tends to appear later Once acute inflammatory response resolves

36
Q

Subluxing peroneal tendons
methods of diagnosis,
clinical presentation (subjective and objective clinical features)
key methods of treatment and management

A

Results from disruption of the superior peroneal retinaculum and usually involves an avulsion of the retinaculum from its fibular insertion

  • MOI typically involves an inversion injury to the dorsiflexed ankle with accompanying forceful contraction of the peroneals
  • Isolated injury is rare (but very possible) and can result in ongoing subluxation and pain– More common in recurrent ankle sprain pathology

Rapid dorsiflexion of an inverted foot. Inversion leading to rapid reflexive contraction of the PL and PB tendons
rapid contraction can also lead to injury to the superior peroneal retinaculum

S/E
• Symptoms over the posterolateral aspect of the ankle
• Painful ‘locking’ or ‘snapping’ along the lateral ankle
with activity
– Tendons sublux anteriorly with contraction or stretch of fibularis muscles in the lateral compartment

• P/E
– Fx tests (Pain with toe walking)
– TOP and swelling are noted over the posterolateral aspect of the ankle and distal leg
– Resisted tests
• Reproduction of pain and subluxation
• Weakness of ankle eversion
• Dx commonly confirmed with US, CT and/ or MR

• Subluxation tends to appear later Once acute inflammatory response resolves

37
Q

Post-traumatic synovitis

A

Early symptoms (Same as for acute sprain)
• Some synovitis inevitable
– Especially where bleeding into the joint and/or
– Where inadequate initial joint protection
– More common with ↑’d sprain severity
• But not always
– Also common in the presence of chronic laxity

• Later symptoms (sub-acute stage)
– Ankle ‘just not right’ and fails to progress beyond subacute stage
– Persistent/recurrent swelling and pain
• Especially post exercise
– Overall slow recovery of function
• May make initially adequate progress but subsequently
unable to progress to higher impact activities without
the above

• Later signs
– Observable swelling along the joint line common
• Usually mild
– Loss of ROM - active and passive
• Pain at EROM
– Focal TOP along joint line
• Lateral ‘gutter’ of lateral joint line TCJ
• Medial STJ and/or TCJ line
• Thickened, odeomatous synovium at joint margins

38
Q

Post-traumatic synovitis

A

Persistent and disabling synovitic reaction to trauma

Early symptoms (Same as for acute sprain)
• Some synovitis inevitable
– Especially where bleeding into the joint and/or
– Where inadequate initial joint protection
– More common with ↑’d sprain severity
• But not always
– Also common in the presence of chronic laxity

• Later symptoms (sub-acute stage)
– Ankle ‘just not right’ and fails to progress beyond subacute stage
– Persistent/recurrent swelling and pain
• Especially post exercise
– Overall slow recovery of function
• May make initially adequate progress but subsequently
unable to progress to higher impact activities without
the above

• Later signs
– Observable swelling along joint line common (mild)
– Loss of ROM - active and passive w Pain at EROM
– Focal TOP along joint line:
• Lateral ‘gutter’ of lateral joint line TCJ
• Medial STJ and/or TCJ line
• Thickened, odeomatous synovium at joint margins

39
Q

Ankle impingement

A

Typically 2° to repetitive trauma to articular
margins and/or soft tissues (synovium) in ant/posterior ankle

• Mechanism(s)
– Repetitive, forced ankle plantarflexion(Ballet point)
– Repetitive, forced ankle dorsiflexion (Kicking sports)
– Acute trauma(Forced plantarflexion or PF/Inv injury)

-Os Trigonum
An extra (accessory) bone that sometimes develops behind the talus.Connected to the talus by a fibrous band. The presence of an os trigonum  is congenital.

2ο ossification centre
May be bruised or fractured
Diagnosis: X-ray, Palpation,Passive PF (end-range) painful

40
Q

Sinus tarsi syndrome:

Definition

Causes

Signs and symptoms

EDIT MIDDLE SECTION

A

Inflammation of the sub-talar ligaments, synovium and fat pad within osseous canal

Causes
• inversion sprains > lesion with persisting inflammation
• repetitive hyper-pronation
– Impingement of the soft tissues within the sinus tarsi
due to STJ/rearfoot instability

• 70% of patients present post supination ankle sprain
• Report anterolateral ankle joint pain
– Over and deep to the sinus tarsi
• Often describe feelings of rearfoot instability during
activity
– Discomfort during foot supination and pronation
– In athletes increased discomfort running on a curve in the direction of the affected ankle

Signs/symptoms
• Swelling in front of the lateral malleolus
• TOP over the opening of the sinus tarsi
• Altered motion of subtalar joint on examination – Hypo/hypermobile
• Pain on forced passive inversion and eversion
• Local anaesthetic can assist Dx

41
Q

Sinus tarsi anatomy

NOT VERY IMPORTANT

A

Sinus tarsi anatomy

  • An anatomical space bound by the talus and calcaneum
  • Talocalcaneonavicular joint lies anteriorly and the posterior facet of the subtalar joint posteriorly

• Medially it is continuous with the tarsal canal/tunnel

The sinus tarsi contains:
the cervical ligament
three roots of the inferior extensor retinaculum

The tarsal canal contains:
Interosseous talocalcaneal ligament
deep and intermediate roots of the inferior extensor retinaculum

42
Q

Plantar fasciosis
AKA = Plantar fasciitis

Describe/define

Where does it occur

Why is fascitis an inappropriate term?

A

• Involves a non-inflammatory stress reaction of the plantar aponeurosis at the medial calcaneal tubercle …
– Affects the fascial enthesis at the medial calcaneal tubercle
- A calcaneal “traction” spur can be a later, secondary, development in response to the repeated mechanical loading

• Fasciitis an inappropriate term
– Rather, an enthesopathy and/or fasciosis
• PF is tendon-like and “aponeurotic” in terms of its tissuecharacteristics and hence tends to behave much like an overuse tendinopathy

Histologic findings from chronic plantar fasciitis

– Myxoid degeneration with fragmentation and degeneration of the plantar fascia
– Bone marrow oedema (calcaneum/enthesis)

• Histologic findings support that:
“plantar fasciitis” is a degenerative fasciosis without inflammation, not a fasciitis
• Findings suggest Rx regimens such as serial corticosteroid injections into the plantar fascia should be reevaluated in the absence of inflammation and in light of their potential to induce plantar fascial rupture

43
Q

Fasciosis

pathomechanics

A

PATHOMECHANICS
• Failure to adapt to/cope with repetative and/or
sustained (cyclic loading) during stance (Mid-late)

•Link between altered mechanical loading & arch mechanics and plantar fasciosis is tenuous
• Alternative mechanisms
– ‘Stress shielding’
– Vascular and metabolic disturbances
• Obese and underactive

– Increase in arch height (associated with the
windlass effect) coincides with peak intrinsic muscle
activity

44
Q

Subjective symptoms with

Plantar fasciosis

A

Common in running athletes with recent changes in
loading pattern or…Sedentary +/- unaccustomed loading

– Gradual onset of burning pain/ache in proximal aspect of medial longitudinal arch

– Sx behaviour quite similar to tendinopathy:

• AM/post-rest stiffness and pain upon initial WB’ing
• Sx may ease with activity
– Aggravated by WB’ing activities that load the PF
• Running/Walking in more severe cases
– Night/rest pain
• Associated with calcaneal oedema

– Can develop acutely with a sudden onset
– Under-diagnosed
– Often missed with NWB MRI

• Partial tears not uncommon

45
Q

Physical exam features of

Plantar Fasciosis

A

• Avoid loading through 1st MTP with heel raises
• Pain on DL/SL heelraise when load through the 1st MTP
• Loss of 1st MTPJ extension (due to reduced PF length)
– May have pain on DF/extn of 1st MTPJ
–Local, mild swelling/“puffiness”
• Local TOP(espec Medial calcaneal tubercle)
• Local “thickening” on palpation, texture change
-Crepitus

46
Q

Common Biomechanical impairments with plantar fasciosis

Local and distant

A 
– Local
• Poor rear- and mid-footcontrol – “Over-” and “under-pronators”
• Loss of ankle DF’n ROM
• Loss of plantarflexor extensibility
• Loss of plantar fascia extensibility
• Calf weakness/poor endurance

– Distant
• Sub-optimal hip control and muscle performance

47
Q

Intrinsic and extrinsic causes of

Medial Tibial Stress Syndrome

A 
Causes:
– Intrinsic
• Excessive/uncontrolled pronation
• Muscle tightness (PF’s)
– Compensatory overpronation
• Running technique
– Extrinsic
• High and/or unaccustomed training loads
• Hard training surfaces
• Poor footwear (inadequate support)

aetiology
• Early thinking….
• Excessive and/or prolonged pronation leading
to +++ eccentric loading of the pronation
decelerators
– Tibialis posterior and FHL

48
Q

MTSS(Medial Tibial Stress Syndrome) vs
TSF(Tibial Stress Fracture)

are there similarities or a continuum

A

MTSS and TSF
• Some authors consider MTSS and TSF to be
conditions on a bone stress-failure continuum
upon which MTSS is a mild expression and
TSF the severe extreme
– No consensus on this
– Some athletes quite clearly develop one condition
without evidence of the other

49
Q

Stress fracture

Symptoms
Xray

Common sites

A
  • Gradual Onset - increased or unaccustomed exercise
  • Deep, nagging pain with exercise & (later) at rest
  • Palp – Point tenderness
  • X-ray:early –ve, late +ve
  • Bone scan +ve
  • Overuse
• Common sites
– Hip (femoral neck)
– Pubic ramus
– Femur
– Tibia
– Navicular
– Metatarsal
50
Q

Compartment (Pressure) Syndrome

Pathology

Presentation

Diagnosis
Treatment

A

• Pathology
– Pain secondary to muscle and nerve ischaemia
– Caused by increased compartment pressure during exercise due to inadequate vascular outflow
• Capillary bed collapses
• Impedes normal oxygenation of neural tissue and
muscles within the compartment
• Tissue hypoxia causes pain
– Activity dependent and eases with rest

• Presentation
– Gradual onset of burning/aching pain 
– Feeling of tightness or fullness
– Typically worse after predictable duration of exercise
– Relieved with rest
– Generalised TOP over the compartment

Diagnosis
– Refer to sport physician
– Post exercise compartment pressure measurements
• Management
– Poor response to conservative treatment??
– Surgery commonly required to return to sport

51
Q

What are the Three discrete compartments
Where compartment syndrome can occur?

Nerve contained inside
Percentage of cases

A 
Three discrete compartments
– Anterior - Deep fibular nerve
• 45%
– Lateral – Superficial fibular nerve
• 10%
– Deep posterior – Tibial nerve
• 45%

Peripheral Musculoskeletal science (13 decks)

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