Week 9 Flashcards
1
Q
A ___ based practice approach is kept in mind for treating sprains in the ankle
A
An impairment based practice approach is kept in mind for treating injuries in the ankle
2
Q
What are the predictor variables that gives a better chance of success for manual therapy and exercise intervention for a grade1-2 ankle sprain?
A
- Symptoms worse when standing
- Symptoms worse in the evening
- Navicular drop > 5 mm
- Distal tibiofibular joint hypo-mobility
(+ LR for success with 3 of 4 variables = 5.90)
3
Q
What are the MT recommendations for the acute/ protected motion of an ankle sprain?
A
• MT for lymph drainage, edema reduction, pain-free
soft tissue and joint mobilizations
• Exercise: reinforce MT; appropriate for stage and goals
4
Q
What are the MT recommendations for the progressive loading /sensorimotor training phase of an ankle sprain?
A
MT: graded mobilization/ manipulation, mobilization with movement
• Exercise: reinforce MT, functional retraining, strength and balance
5
Q
What are some alternate techniques to address ankle and foot sprains?
A
Subtalar/rearfoot manipulation AKA talocrural joint thrust or distraction technique (high velocity technique)
6
Q
The subtalar/rearfoot manipulation AKA talocrural joint thrust (TCJ thrust) or distraction technique is often utilized to ____
A
The subtalar/rearfoot manipulation AKA talocrural joint thrust or distraction technique is often utilized to help restore mobility in the direction of DF
7
Q
What is the difference between a the mobilization with movement technique, vs the mobilization with movement technique?
A
No between group difference
8
Q
What is a caution to take in the acute phase of an ankle sprain?
A
Avoid increased pain
9
Q
What are some things to do during the clinical decision making process for ankle sprains?
A
- Perform a lumbar/lower quarter screen, especially if chronic
- Assess functional comparable sign
- Address Common Mobility Impairments (DF, eversion…)
- MT & Exercise (including proprioception)
- Reassess functional comparable sign
10
Q
What is plantar heel pain (PHP)?
A
Pain arising from insertion of the plantar fascia
11
Q
PHP can be with or without a ___
A
PHP can be with or without a heel spur
12
Q
What is the presentation of PHP?
A
- Progressive pain with weight-bearing
- Especially 1st steps in the morning
- Present in both athletic and non-athletic populations
13
Q
There is rarely a case of __ present with PHP
A
There is rarely a case of inflammation present with PHP
14
Q
Which group of patients experienced greater improvements in PHP between an E-stim group vs a MT and exercise group?
A
MT and exercise group
15
Q
What is cuboid syndrome?
A
Pain plantar region of cuboid
16
Q
What is the mechanism of a cuboid syndrome?
A
Forceful contraction of the
peroneus longus with plantar subluxation.
17
Q
What is the prevalence of cuboid syndrome in the population?
A
- Dancers: 17% of foot/ankle injuries
- Athletes: 4% of foot injuries
- Lateral ankle sprains: 7%
18
Q
What are the presentations of cuboid syndrome?
A
• Pain during gait; reduced
push-off.
• Localized pain & tenderness over the cuboid.
• Pain with passive physiological and accessory motion testing in the midfoot and cuboid region.
19
Q
What is hallux rigidus/limitus?
A
Degenerative arthrosis 1st MTP
20
Q
What populaton does hallux rigidus/limitus affect the most?
A
Over 50
21
Q
What is hallux valgus?
A
An ABD hallux position
22
Q
What population is hallux valgus mostly present in?
A
- Incidence increases with age
- 3% 15-30 years
- 9% 31-60 years
- 16% > 60 years
- More in males than in females
23
Q
What is the post-op PT care for hallux valgus?
A
- Edema reduction
- Gait training /1st ray weight bearing
- Muscle re-education/ strengthening
- MT: mobilization to increase MTP F/E; oscillating toe traction for pain control; other foot/ankle joints as indicated
24
Q
At what stage of post op ankle fracture do we do the most of MT techniques?
A
At the immobilization phase, then we decrease it as patient gets more mobile and increase exercise
25
What are the risk factors of PHP?
* Limited ankle dorsiflexion
* Prolonged standing during the day
* BMI > 30 kg/m2
26
What are the potential underlying factors of PHP?
* Pes planus with subsequent overstretch of fascia
* Rigid, cavus foot with tight fascia
* Sudden increase in frequency, intensity, duration of activity (esp. hill or speed work for runners)
* Calcaneal spur may develop due to chronic pull of fascia on calcaneus
27
What are the selected objective exam factors of PHP?
* Pain with palpation of plantar fascia insertion
* Limited DF ROM
* Higher BMI in non-athletic individuals
* Positive windlass test
* Negative tarsal tunnel test
* Possible impaired neurodynamics
* Assumes cleared up through L-spine for contributing conditions (mobility and strength)
* US thickness > 4mm at calcaneal attachment
28
MT addresses relevant LE impairments using what techniques?
* Joint mobilizations
| * Soft tissue mobilization
29
MT techniques can be combined with ___ to treat LE impairments
MT techniques can be combined with *targeted exercise* to treat LE impairments
30
What are the goals of MT in regards to LE impairments?
* Address joint mobility
* Improve flexibility deficits
* Decrease pain
* Restore function
31
What are the other intervention methods for PHP?
* Stretching – Grade “A”
* Taping – Grade “A”
* Foot Orthoses – Grade “A”
* Night Splints – Grade “A”
* Physical Agents – variables grades from “C” to “D”
* Therapeutic Exercise – no studies were reported in CPG specific
* Trigger Point Dry Needling – insufficient evidence at present,
32
What are the target tissue for stretching as an intervention for PHP?
* Plantar fascia specific
| * Gastroc/soleus
33
What sort of relief results from stretching as an intervention for PHP?
Short-term relief
34
What type of taping is used for PHP intervention?
Low-Dye (antipronation) taping
35
What sort of benefits are present for taping as an intervention for PHP?
* Short-term benefit per application (~ 48 hrs)
| * May be of benefit to ease pain/restore function early in care
36
Who is a foot orthoses potentially useful for as a PHP intervention?
Potentially useful for those who respond favorably to taping
37
What kind of effects are present for foot orthoses as an intervention for PHP?
Short to long-term
38
How long are night splints prescribed for as a PHP intervention?
Prescribe for a duration of 1-3 months for those with consistent 1st step pain
39
Does the type of night splint affect the outcome in PHP?
Type of night splint does not appear to affect outcomes
40
What type of physical agents can be used as an intervention for PHP, and why are they scored so low?
Iontophoresis, phonophoresis, ultrasound, low level laser.
They scored so low, because there is no inflammation in PHP
41
What are the systemic conditions that can cause heel pain?
Includes neuropathy and inflammatory arthritis causing conditions
42
What is fat pad syndrome?
Generally degenerates > age 40yrs, after injury or recurrent stress
43
What is the effect of a fat pad syndrome?
Reduced cushioning
44
What are PT management options for fat pad syndrome?
Activity modification
• Doughnuts/ heel cups or heel pads
• Cushioned footwear
• Ice
45
What is tarsal tunnel syndrome?
Posterior tibial nerve (or med/ lat plantar nerve) entrapment as it passes posterior to medial malleolus
46
What are the causes of tarsal tunnel syndrome?
* Trauma
* Excessive pronation/ pes planus
* Tight laced shoes /boots
* Local edema/ inflammation
* Space occupying lesion (i.e. tumor)
47
What are the exam findings of a tarsal tunnel syndrome?
* Burning, numbness/tingling in medial ankle and/or plantar foot
* Plantar foot parethesias
* (+) Tinels to posterior tibial nerve with simultaneous DF/EV & toe extension
* MMT changes (rare)
* Max passive ankle EV/DF and MTP/IP extension held 5-10 sec
48
What is the usual onset of of a calcaneal stress fracture?
Sudden or gradual onset pain
49
Calcaneal stress fractures are typically associated with __
* Increase in load >normal bone capacity
| * Falls/impact
50
What activities are usually painful with a calcaneal stress fracture?
Pain with all weight bearing activities
51
What are the exam findings of a calcaneal stress fracture?
Pain with
• Calcaneal palpation along medial/lateral aspect
• Calcaneal squeeze, percussion
52
What is posterior tibialis dysfunction?
Pain, inflammation along posterior tibialis tendon and
| sheath – may show anywhere along tendon to plantar aspect of foot
53
What are the presentations of posterior tibialis dysfunction?
* Can have pain with weight bearing, which may ease thru day
* Gait, push-off deficits
* Decreased posterior tibialis length with testing
54
____ ankle sprain is the least stable in “loose packed” position that occurs in ___
*Lateral* ankle sprain is the least stable in “loose packed” position that occurs in *PF with inversion*
55
What is the progression of severity for a lateral ankle sprain?
Progression of severity from ATFL to CFL to PTFL
56
Why is the medial ankle sprain less common?
Less common due to decreased eversion ROM and bony architecture
57
____ is a high ankle sprain and is the least common type of sprains
*Syndesmotic* is a high ankle sprain and is the least common type of sprains
58
What are the presentations of a grade 1 acute lateral ankle sprain?
* Mild symptoms
* Likely kept playing after injury
* Microscopic tearing of ATFL
* No functional loss or instability
59
What is the recovery time of a grade 1 acute lateral ankle sprain?
• Recovery time: 2-10 days
60
What is the treatment method of a grade 1 acute lateral ankle sprain?
Patient self treatment
61
What are the presentations of a grade 2 acute lateral ankle sprain?
* Moderate functional loss
* Involves ATFL and CFL
* May have initially “walked it off” but will have gait dysfunction
* Diffuse swelling/tenderness
62
What is the recovery time of a grade 2 acute lateral ankle sprain?
• Recovery time: 10-30 days
63
What type of acute lateral ankle sprain is most commonly seen in PT?
Grade 2 acute lateral ankle sprain
64
What are the presentations of a grade 3 acute lateral ankle sprain?
* Unstable, multi-ligamentous sprain
* Anterior capsular involvement
* Unable to fully WB
* Diffuse edema/tenderness
* Frequent concomitant fracture
65
What is the recovery time of a grade 3 acute lateral ankle sprain?
• Recovery time: 30-90 days
66
What is the typical management method of a grade 3 acute lateral ankle sprain?
Typically managed by ortho first
67
What is the grading for a grade 1 acute lateral ankle sprain on a west point sprain grading system?
- Tearing: Microscopic
- Swelling: Minimal
- Joint stability: None
- Weight bearing: Fully/partial
68
What is the grading for a grade 2 acute lateral ankle sprain on a west point sprain grading system?
- Tearing: Partial
- Swelling: Moderate/swelling
- Joint stability: Mild/moderate
- Weight bearing: Partial/unable
69
What is the grading for a grade 3 acute lateral ankle sprain on a west point sprain grading system?
- Tearing: Complete rupture
- Swelling: Severe
- Joint stability: Moderate/severe
- Weight bearing: Unable
70
What are the test done for an acute lateral ankle sprain?
* Anterior Drawer
| * Talar Tilt Test
71
What ligament does the anterior drawer test test for in an acute lateral ankle sprain?
Tests for ATFL
72
When is the diagnostic accuracy better for the anterior drawer test?
Better diagnostic accuracy 5 days post-injury compared to 2 days post-injury
73
What ligament does the talar tilt test test for in an acute lateral ankle sprain?
Tests for CFL
74
What are the things that we are looking for in the talar tilt test?
- Does it produce pain?
- Do we find more joint play compared to the other side
- Is there more of a 5 deg difference with how much excursion we get compared to the uninvolved extremity
75
What are some common sinister issues that can happen with an inversion sprain?
* Nerve: superficial peroneal /fibular nerve involvement
* Base of the 5th MT
* Spiral fracture of the fibula
* Lateral malleoli
* Navicular
76
What are the ottawa ankle rules for deciding if a patient needs a x-ray for when they experience pain over the malleolar zone?
- Any pain over the malleolar zone and any of these findings:
- Bone tenderness at the posterior edge or tip of lateral malleolus 6cm
- Bone tenderness at the posterior edge or tip of medial malleolus 6cm
- Inability to bear weight both immediately and in emergency department (2-3 steps)
77
What are the ottawa ankle rules for deciding if a patient needs a x-ray for when they experience pain over the mid-foot zone?
- Any pain in mid-foot zone and any of these findings:
- Bone tenderness at base of 5th metacarpal
- Bone tenderness at navicular
- Inability to bear weight both immediately and in emergency department (2-3 steps)
78
What are the characteristics of a medial/eversion sprain?
* More severe
* Potential for mortise instability
* Medial malleolar fracture
79
Where is the pain for a medial/eversion sprain?
Localized pain over the deltoid
80
What is the test for the medial/eversion sprain?
Positive eversion (talar tilt) test
81
What is a syndesmotic (high ankle) sprain?
Injury to anterior tibio-fibular ligament and/or syndesmosis
82
What is the mechanism of a syndesmotic (high ankle) sprain?
* Hyper-dorsiflexion
| * Rotation and PF
83
How long is the recovery time for a syndesmotic (high ankle) sprain?
Recovery >6 months
84
What is often the intervention for a syndesmotic (high ankle) sprain?
Often surgical candidate
85
What are the special test for a syndesmotic (high ankle) sprain?
* Syndesmotic squeeze
* ER stress test
* Fibular translation test
86
What is the acute management of an ankle sprain?
- Initial pain and edema control (RICE)
- Gait (crutches)
- Early mobilization and WB
87
What type of sprain is immobilization indicated for?
Indicated in grade III injuries as well as syndesmotic injuries
88
What does immobilization lead to in a grade 1 and 2 injury?
Leads to protracted recovery in grade I and II injuries
89
___ WB ideal immediately post-injury
*Protected* WB ideal immediately post-injury
90
What does manual therapy do for an ankle sprain?
Thrust and non-thrust techniques may improve pain and function following acute ankle sprain
91
What does therapeutic exercise do for an ankle sprain?
Exercise therapy reduced risk of recurrent ankle sprains and functional instability
92
___ is a great way to start treatment for an ankle sprain, but not the best place to finish
*Neuromuscular training* is a great way to start treatment for an ankle sprain, but not the best place to finish
93
Chronic ankle instability is characterized by residual symptoms that include ___
Chronic ankle instability is characterized by residual symptoms that include *feelings of giving way and instability as well as repeated ankle sprains, persistent weakness, pain during activity, and self-reported
disability*
94
What are the 2 primary components of chronic ankle instability?
- Mechanical instability
| - Functional instability
95
What are the mechanical instability components of chronic ankle instability?
Pathologic laxity, impaired arthrokinematics, and joint degenerative changes
96
What are the functional instability components of chronic ankle instability?
Altered neuromuscular control, strength deficits, and deficient postural control
97
___ or ___ is recommended for return to sports and has been proven to really work
*Lace-up or semi-rigid brace* is recommended for return to sports and has been proven to really work
98
What are the ways to test for closed chain DF in patients with ankle sprain injuries?
- 38 degree tibial shaft angle
| - 9-10cm knee to wall
99
What is the patient progression of pain or disability?
- Self management
- Conservative car (PT)
- Surgery
100
What are the indications for surgery in the foot and ankle?
- Pain
- Loss of function
- Instability
101
What are the soft tissue repairs surgical procedure of the ankle and foot?
* Achilles Tendon Repair
| * Tarsal Tunnel Release
102
What are the stabilization procedures and arthroplasties surgical procedure of the ankle and foot?
* Lateral Stabilization
* Lis Franc Fusion
* Ankle Fusion or Replacement
* 1st MTP Replacement
103
What are the general repairs surgical procedure of the ankle and foot?
• Osteochondral grafting of the
talus
•Hallux Valgus Repair
104
What are the indications of an achilles tendon repair?
- Rupture
- Young and active
- Not musculotendinous joint
105
What are the indications of a tarsal tunnel release?
- Tarsal tunnel syndrome
- Increased motor nerve latency on EMG
- Early diagnosis
- Identifiable lesion
106
What are the descriptions of n achilles tendon repair?
Open or percutaneous
107
Which form of intervention is better for an achilles tendon repair Surgery vs Conservative
Care?
Surgery
108
What are the rehab considerations for an achilles tendon repair?
* Accelerated rehab
* Protocols vary
* Operative cases usually 4 weeks ahead of Nonoperative
109
What does the accelerated rehab for an achilles tendon repair consist of?
- Immobilization in a PF position for 2wks after surgery
| with the possibility of FWB immediately after surgery using a walking boot and a heel lift
110
When are progressive resistive exercises initiated for an achilles tendon repair?
Week 6
111
What happens at 7 weeks post op of an achilles tendon repair?
ROM can be progressed As tol, with the patient being able to be out of the walking boot
112
How long does recovery of an achilles tendon repair take and how long is the return to sport time foe an achilles tendon repair?
Recovery takes 6-9 months and return to sport can take up to 12 months or longer
113
What are some conservative treatments to do prior to a tarsal tunnel release surgery?
- Immobilization
- Orthotics
- Strengthening and balance activities
- Pharmocological medications
- Injections
114
What are the post op priorities of a tarsal tunnel release surgery?
* 3 Weeks Immobilization, Non-weight Bearing
* Tissue Mobility (incision, mobilization, gentle nerve glides)
* Progression into DF, and Start Gait Training & Functional Re-Training
115
How long does it take to return to sport post tarsal tunnel release surgery?
2 and a half months
116
What is the indication for an Osteochondral grafting of the
| talus?
* Osteochondritis dissecans
| * Lesion of articular cartilage
117
What is the indication for a Hallux Valgus Repair
• Bunion correction/ painful hallux valgus deformity
118
How are chondral lesion of the talus usually identified?
Via MRIs as an increased signal intensity of the talar dome
119
What is required for an Osteochondral grafting of the
| talus?
Donor tissue required, usually from less weight-bearing region of knee (OATS)
120
What are the rehab considerations of an osteochondral grafting of the
talus?
* Tissue/Osteotomy healing
| * ROM
121
When a patient has a small lesion, what kind of graft should be used?
None, do an arthroscopic surgery instead of OATS
122
When a patient has a large lesion, what kind of graft should be used?
Allograft, because an autograft will not yield as good of an outcome
123
The common surgical procedure for an hallux valgus
| deformity involves ___
The common surgical procedure for an hallux valgus
| deformity involves *an osteotomy / ORIF procedure*
124
What are the post op priorities of a hallux valgus deformity surgery?
* Bone healing
* Great toe extension
* Gait training
* Neuromuscular reeducation
125
What is the common complication of the hallux valgus deformity surgery?
Lingering 1st toe MTP joint extension ROM loss
126
What are the indications for a lateral stabilization procedure?
Gross, or chronic ankle instability
127
What are the indications for a lis franc fusion procedure?
Fracture, sprain
128
What are the indications for an ankle fusion and arthroplasty procedure?
* Complex Fractures
| * Degenerative changes
129
What are the indications for a 1st MTP arthroplasty procedure?
Degenerative changes, pain, limited mobility
130
What patients are lateral stabilization procedures used for?
Patients following a severe or repetitive ankle sprains that have not responded to conservative care, after about 6 months of failed rehab
131
What are the 2 main types of lateral stabilization procedures?
Anatomic and non- anatomic
132
What does the anatomic lateral stabilization involve?
Reconstruction of the lateral ligaments
133
What does the anatomic lateral stabilization involve?
Brostrom: consist of rerouting the peroneal muscles or utilizing harvest tissues from other parts of the body to help stabilize the lateral ankle
134
Which type of lateral stabilization technique has yielded better results?
Anatomic
135
What are the rehab protocols following a lateral stabilization technique?
- Ankle immobilization for 2 weeks
- Gently ROM and gait training after 2-3 weeks
- PROM into inversion 6 weeks post op
136
When is the anticipated return to sport for a lateral stabilization technique?
3-6 months
137
What are the benefits of fusions for a Lis Franc Fusion?
- Decreased chance of a 2nd surgery
| - More stable in the long term
138
When are patients immobilized and NWB in a lisfranc fusion/ ORIF?
1st 6 weeks
139
What should be happening 6 weeks post op of a lisfranc fusion/ ORIF?
- Foot and ankle ROM activity should be slowly initiated followed by flexibility, proprioception, and strengthening activities
140
___ is often utilized post a lisfranc fusion/ ORIF procedure to help maintain and protect the healing structures during the recovery process
*Orthotics* is often utilized post a lisfranc fusion/ ORIF procedure to help maintain and protect the healing structures during the recovery process
141
When is the anticipated return to sport for a lisfranc fusion/ ORIF?
Within 6 months of surgery
142
What is an arthrodesis?
Bone glue/grafts and screws
143
Both an arthrodesis and arthroplasty for the ankle require and initial ___ status, while allowing the tissues to heal
Both an arthrodesis and arthroplasty for the ankle require and initial *NWB* status, while allowing the tissues to heal
144
How long is the NWB time for an arthroplasty and how long for the arthrodesis?
Arthroplasty: 2 weeks
Arthrodesis: 8 weeks
145
What is the return to sport time for an arthroplasty and how long for the arthrodesis?
Arthroplasty: 4 months
Arthrodesis: 6 months
146
How long does it take for maximal recovery of an ankle arthroplasty and arthrodesis?
1 year
147
What is the primary goal of arthroplasty of the 1st MTP joint?
Maintain ROM and function of the 1st toe
148
What is the gold standard surgery for the 1st MTP joint?
Arthrodesis is the gold standard
149
What are the effects of a arthrodesis in the 1st MTP joint?
- Reduces pain
- Maximizes clinical outcomes
- Reducing complications and the potential for revisions
150
What is the downside of an arthrodesis for a 1st MTP joint procedure?
It modifies gait, due to a loss of general toes extension ROM and limits footwear that can be worn and tolerated
