wk 11- achilles/ ankle/RF pain Flashcards
types of achilles pain
midportion
insertional tendinopathy
achilles rupture
explosive activity with a loud crack and initial feeling of being kicked
more common in males
assessments for achilles rupture
calf squeeze test
simmonds test
thompsons test
treatment for achilles rupture
- referral to orthopeadic surgery for repair
- conservative rehab
what tendon is medial to the achilles
plantaris tendon
stages of achilles tendinopathy
stage 1- reactive tendinopathy: short term adaption to overload. non inflammatory proliferative response, tendon thickens
this can reverse back to normal if given time to rest between loading and overload is reduced
stage 2- tendon dysrepair
tendon attempts to heal with matrix breakdown (increase number of cells and vascularity on ultrasound)
stage 3- degenerative tendinopathy
progression of matrix disorganisation/breakdown, cell changes and neovascularisaton
if load not reduced, rupture as the tendon is structurally unable to transmit tensile loads
reactive on degenerative:
structurally normal portion of tendon may go in and out of a reactive response
clinical features of mid portion achilles tendinopathy
pain/stiffness 2-6cm above posterior calc
burning pain
pain increased with activity and relieved with rest
thickening palpated
negative calf squeeze test
postitive royal london hospital test - pain absent on max dorsiflexion
what is there little evidence on correlation with achilles tendinopathy
STJ pronation
intrinsic and extrinsic risk factors for achilles tendinopathy
int:
1. weak plantarflexion strength
2.increased/reduced dirsflexion ROM
3. reduced knee flexor strength
4. poor tendon structure
ext:
1. increased tendon loading with activities
2. FW
3. surface
imaging for achilles tendinopathy and what to look for
- US
-tendon thickening
-neovessels
-hypoechogenic
-disorder fibres
-tissue gaps
-fluid
management of achilles tendinopathy
- alfredsons protocol
3x15 reps twice a day, every day for 12 weeks
knee straight and bent knee lowering on injured leg
can progress with weight
if theres improvement continue for 6-12 months
- 4 stage achilles rehab program
- isometric calf raise 45sec, 4-5reps with 2 mins rest. completed 2-3 times a day
-isotonic calf raise, slow eccentric. twice a week
-energy storage, slow skipping 3 times a week
-energy storage and release - if theres no improvement
-modify load/activtiy
-consider other modalities like electrotherapy,massage, GTN patch
-surgery last resort
what can plantaris do to achilles
compresses achilles
or ensheafed in tendon
how to know if theres plantaris involvement in achilles pain
-pain more medial ad proximal
-pain aggrevated by loading in dorsiflexion
what type of tendinopathy is most common
mid portion
how does insertional achilles tendinopathy occur
excessive tendon load with compression against the calc
excessive dorsflexion with high tensile loads
increased compression when pushing against resistance
running uphill
clinical features of insertional achilles tendinopathy
palaption of posterior calc causes pain
there may be pain on dorsiflexion
swelling
royal london test
management of insertional achilles tendinopathy
- deload
2.avoid barefoot/ heel raises
3.staged loading rehab (alfred or 4 stage) avoiding dorsiflexion (not on step) - dont over stretch
bone pathology of the ankle/RF
talar dome lesion
calcaneal apophysitis
soft tissue pathology of ankle and RF
post tib tendinopthy
post tib dsfunction
peroneal tendinopthy
tib ant tendinopathy
FHL tendinopthy
achilles tendinopathy
retrocalcaneal bursitis
joint pathology of ankle
ankle impingement anteiror/posteiror
neural/vascular pathology of ankle
tarsal tunnel syndrome
talar dome lesion is what
osteochondritis dissecans of the talar dome
(subchondraol bone and articular cartilage separate from underlying bone)
how does talar dome lesions occur
trauma/injury (inversion ankle sprain that doesnt improve with conservative treatment)
vascular failure
genetic predisposition
posterior medial talar dome lesions occur by
foot plantarflexed during inversion
anterolateral talar lesion occurs when
foot is dorsiflexed
clinical features of talar dome lesion
pain around anterior ankle when plantarflexed
swelling
stiffness/ reduced ROM
popping, clocking, locking (loose body)
management of talar dome lesion
- immobilise in NWB cast 3-4weeks
- then immobilise in CAM walker 6-10 weeks
- surgery
what is post tib tendon dysfunction
loss of dynamic and static support of MLA, hindfoot, ankle (not just post tib)
dynamic:
-plantar aponeurosis
-post tib tendon
-plantar intrinsic muscles
static:
-spring lig
-superficial deltoid lig
-long and short plantar lig
-plantar aponeurosis
flat foot deformity
risk factors of PT dysfunction
-40years and more
-woman
-obese
-hypertension
-diabetes
-trauma or surgery to medial aspect of foot
patho of PTTD
- existing flatfoot
- increased gliding resistance of PTT
-everted hindfoot unlocks midtarsal joint during midstance/terminal and heel rise
-increased strain on supportive ligamnents and post tib
-attenuation and rupture of PTT
-rupture of spring lig, deltoid and plantar ligs
soemone with long standing flexible flat foot is prediosposed to
PTTD
stages of PTTD
1- tensosynovitis (flexible)
2- atteuation or rupture (flexible, may not be able to heel raise)
3- complete rupture (rigid)
4- valgus talo crural joint (rigid)
assessing PTTD
-double and single leg raises
look for heel heights and supination
if unable to perform heel raise it indicates stage 2 PTTD
-jacks test- windlass mechanism
-assess flexibility of rearfoot
inversion and eversion
if rigid then its a sign of stage 3/4 PTTD
-assess NWB muscle strength
-supination lag: getting patient to plantarflexed and bring soles together (less movement in PTTD)
treatment for PTTD depends on
stage
stage 1 PTTD management
- reduce inflammation
- immobilise (CAM walker, bracing, taping low dye
- footwear modifications (medial wedge, flares)
- orthoses
stage 2 PTTD management
- immobilise (CAM walker 1-6 weeks
- custom foot orthoses - kirby skive, inverted poor
- custom hinge AFO (richie brace)
- footwear modifications
- rehab program
stage 3 PTTD management
- if no severe DJD (degenerative joint?) in ankle and hindfoot then restricted hinge AFO (richie brace)
-if there is Gauntlet with flexible AFO shell
stage 4 PTTD mangement
gauntlet with rigid AFO shell
what does a richie brace do
treats PTTD
foot drop
chronic ankle instability
types
standard
dynamic
gauntlet
FHL tendinopathy caused by
repetitively going onto toes when plantarflexion is required
wearing shoes too big
walking down hill (gripping of toes)
associated with posterior impingmenet syndrome
enlargement of os trignonum compresses FHL
FHL runs between sesamoids plantar 1st MTPj
clinical features of FHL tendinopathy
-pain with toe off or forefoot loading
-pain when landing
-aggrevated with resisted flexion or passive stretch into dorsiflexion
management of FHL tendinopthy
- rest
- FHL isometric/isotonic strength
- soft itssue therapy
- orthotics
- taping
peroneal tendinopathy
most common lateral ankle pain
causes
1. inversion injury (overstretch of tendon)
2. overuse due to RF eversion/ lat deviated STJ
3.tight ankle plantar flexors causing an increase load on lateral muscles
4. overuse due to dancing, jumping, soft footwear
types of peroneal tendinopathy
- posterior to lateral malleoli (most common)
- peroneal trochlea
- plantar surface of cuboid
clinical features of peroneal tendinopathy
lateral ankle or lateral heel pain worsens with activity
tenderness along peroneal
pain on passive inversion and resisted eversion
tight calf muscles
management of peroneal tendinopathy
- immobilise/rest (CAM walker)
- soft tissue therapy/manual therapy
- lateral heel wedge
- eccentric strength with eversion
tib ant tendinopathy
overuse of tib ant due to
1. restriction in ROM
2. stiffness in ankle
3. walking/running downhill
clinical features of tib ant tendinopathy
-pain, swelling, stiffness in anterior ankle
-occasional crepitus
-aggrevated by walking running up hills or stairs
-tenderness along tendon
-resist dorsiflexion and eccentric inversion gives pain
management of tib ant tendinopathy
1 rest
2. soft tissue theray, amnual therapy
3. address cause
4. eccentric strengthening
what is ant ankle impingment
common in football and ballet dancers
soft tissue or bone compresses between the talus and tibia during dorsiflexion
clinical features of ant ankle impingement
vague discomfortable at front of ankle which becomes sharper and more localised with dorsiflexion
lunge test is painful and typically shoes limited range
management of ant ankle impingement
- heel raise
- rest- limit dorsiflexion
- NSAIDs
- manual therapy
- taping
- arthroscopic removal if exostosis
what is posterior ankle impingement
soft tissue or bone compresses between tibia and superior aspect of calc
common in footballer, ballet dancers
can occur in enlarge posterior tubercles or ostrignonum
sinus tarsi syndrome
interosseous ligaments, synovial membrane, blood vessels, fat and connective tissue located in this area that can be compressed and cause synovitis/inflammation
clinical features of sinus tarsi syndrome
vague, pain near anterior/lateral mall
pain worse in morning and improves with activities
pain worse on uneven surfaces
pain on passive eversion and inversion of STJ
tenderness on palpation and over ATFL
management of sinus tarsi syndrome
- rest
- NSAIDs, ice
- movilisation of STJ
- CSI in sinus tarsi
- address biomechanics
- proprioceptive and strength trainign
calc stress fracture clinical features
-intense diffuse heel pain along medial and lateral aspect of posterior calc
-pain worse wb and activity
-persistent night pain
-positive squeeze test or pain on direct compression
managament of stress fracture of calc
- immobilise (CAm walker, soft cast) 4-8weeks
- rehab strength program
- heel cushions
- assess biomechanics, BMD, training load, footwear, etc
what is plantar heel pain (plantar fasciopathy)
overuse condition of the plantar fascia at its attachment to the calc
risk factors for plantar fasciopathy
- running (cavus foot and hindfoot in runners)
- BMI
- standing time/walking on hard surfaces
- impactful daily activities
- high arch
- reduced ankle dorsflexion
- hammy tightness (8x more likely to have heel pain)
8.leg length difference
patho of plantar fasciopathy
- reduced neuromuscular activity in the muscles in the foot leading to increased loads of the fascia
or
- mechanical deficiency in the fascia which makes it unable to take normal levels of stress
clinical features of plantar fasciopathy
- heel pain after increase in WB actvitiy
-pain worse in morning when getting out of bed
-pain on palpation of proximal insertion of fascia
-positive windlass test
-negative tarsal tunnel test
-abnormal FPI score
-BMI
plantar medial heel pain
most noticeable with initial steps after inactvitiy and worse following prolonged wb
ddx for heel pain
spondylarthritis
fat pad atrophy
plantar fibroma
baxters nerve entrapment
a fascial tear
heel spur
calc stress fracture
what is a common radiographic finding in heel pain
calc spurs
what is the thickness looking for in US for fascia
> 4mm
management of plantar heel pain (1st)
3 teirs
1st:
-padding and strapping, low dye
-stretching fascia and calf
-footwear advice with cushioning and support
-NAIDS
-arch support
-prefab with heel cup, pad
2nd tier PHP
AFTER 6 WEEKS
2nd tier:
- corticosteroid injection
-dry needling for lower limb muscles
-custom orthotics
-immobilisation
-high load strength (heel raises with towel under toes)
3rd tier
after 6 months
3rd tier
-night splint / strassburg sock
-shockwave therapy
-surgery plantar fasciomoty fasciectomy
fat pad syndrome
damage, atrophy, inflammation, contusion
common in elderly (50yrs) and diabetes
clinical features of fat pad syndrome
deep, non radiating pain
WB portion of calc tubercle
barefoot makes worse
pain on palpation of central plantar aspect of heel
management of fat pad syndrome
- NSAIDs/paracetamol
- footwear modifications to reduce plantar pressure (aperture)
- silicine heel cup
- reduce WB activities
- footwear advice (cushioning)
- taping- heel lock, x arch taping
what is piezogenic papules
minor herniation of adipose tissue that surrounds the calc
may be associated with ehlers dnalos sydnrome
common in long standing, marathon runners, weight lifters
managament of piezogenic papules
- corticosteriod injection
- deoxycholic acid injection (breaks down cells in fatty tissue)
- reduce standing
- compression stockings
- soft heel cups
what is baxters nerve entrapment
entrapement of the 1st branch of lateral nerve which innervates abductor digiti minimi muscle
can be entrapment between deep fascia of adductor hallicus and quadratus plantae or anterior calc near the medial calc tubercle
clinical features of baxters nerve
-medial/plantar heel pain
-worse at night and is constant
-tenderness over medial aspect of plantar heel
-inability to abduct 5th toe
-no sensory deficits
management of baxters nerve
- NSAIDS
- shock absorbing innersoles
- MLA support
- steroid injections
if no change after 6 months
5. surgery
tarsal tunnel syndrome
tibial nerve compression in the tunnel
uncommon but occurs from fracture or dislocation of the medial ankle area
clinical features of tarsal tunnel
-aching, burning, numbness
-radiating pain in calf
-worse at night and standing
-prominent tinel’s sign
-dorsiflexion/eversion test which stresses tibial nerve
management of tarsal tunnel
- NSAIDs
- footwear modifications
- CSI
- surgery
what is sondyloarthrophy?
