MSPT I > Ankle: Exam 2 > Flashcards

Ankle: Exam 2 Flashcards

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1
Q

Lateral Ankle Sprains

MOST COMMON LIGAMENT INJURED

A

ATFL

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2
Q

Lateral Ankle Sprain

MOST common ligament injured THEN….

A

ATFL FIRST

followed by:

CFL, PTFL

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3
Q

Lateral Ankle Sprain

MOI

A

Ankle PF and INversion

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4
Q

Lateral Ankle Sprain

Risk Factors

A
  • Hx of PREV ankle sprain
  • Do NOT use an EXT. Support
  • Do NOT properly warm-up
    • ​timing—-warm up peroneals!!!
  • Do NOT have normal ankle DF ROM
  • Do NOT participate in balance/proprioceptive prevention program when there is a hx of prev. injury
    • ​this is often LAST PART OF REHAB***
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5
Q

Lateral Ankle Sprain

Clinical Presentation

A
  • Localized pain @ Anterolateral ankle
    • ​ATFL>CFL>PTFL
  • Effusion (edema)
  • POSSIBLE diff. bearing weight
  • POSSIBLE ecchymosis (bruising)
    • ​why?
      • ​sm. blood vessels ruptured during FIRST injury——following injuries have LESS ecchymosis****
  • (+) Ant. Drawer Test and/or Talar Tilt Test
    • ​remember Stabilize Medially if TESTING LATERAL SIDE
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6
Q

Anterior Drawer Test of the Ankle

  • If assessing Medial (Deltoid) Ankle
    • ​Stabilize laterally
  • If assessing Lateral Ankle
    • ​Stabilize medially
A
  • Tests for injury of ATFL
    • ​can also use for Deltoid Lig.
  • Pt. seated over edge of table w/ ​ankle in SLIGHT PF (~20degs)
  • Apply ANT. GLIDE of talus on stabilized tibia
  • (+) Test= excess. translation of one side in comparison to opp. extremity
  • Discuss/Understand Diff:
    • Lateral aspect of talus translates too far anteriorly ==== Lat. Ankle sprain
    • ​ENTIRE TALUS translates too far anteriorly==Lat & Med. side injury****
  • Sn=.58
    • 42% FN’s
  • Sp= 1.00
    • 100% Negs are Negative
  • +LR=INF (want >10)
    • VERY SURE YOU HAVE IT IF (+)
  • -LR= .42 (want
    • NOT SMALL ENOUGH TO BE SIG.
    • cannot put a ton of stock in a negative test
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7
Q

Talar Tilt Test

*For Lateral Ankle sprain

A
  • Tests for injury to the CFL
  • pt lies SUPINE w/ ankle in neutral
  • examiner brings ankle into INVERSION
  • (+) Test= excess. motion compared to uninvolved side
  • Sn= .50
    • 50% FN’s
  • Sp= .88
    • 12% FP’s
  • +LR= 4.00
    • want >10
  • -LR= .57
    • want
    • cannot put a ton of stock into a negative test
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8
Q

Lateral Ankle Sprain

Interventions: depends on severity

A
  • RICE (24-48hrs or longer)
  • Bracing
    • aircast, Swedo, etc..
    • taping as indicated
  • Crutches
    • IF unable to WB w/out pain
  • Gradual active ankle ROM w/in limits of pain
  • Gradual PREs w/in limits of pain
    • ​DF, EV****
  • Gradual WB w/in limits of pain
  • Balance/Proprioception ex’s
  • Gradual progression of walking, running
  • Manual Therapy as indicated
    • **to correct Anterior Talar positional fault, OR Ant/Inf. Fibular positional fault
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9
Q

High Ankle Sprain

A
  • Injury to Distal tibiofibular syndesmosis:
    • ​AITFL–ant. inf. tibiofibular lig.
    • PITFL– post. inf. tibiofibular lig.
    • Interosseus lig.
    • Interosseus memb.
  • MOI:
    • 3 proposed MOIs:
        1. ER of foot
          * OR tibia rotating INT. on Planted Foot
        1. Eversion of Talus
        1. Excessive DF
  • Mortise widens too much; Talus becomes unstable w/in mortise
  • Risk factors
    • skiing, football, soccer and other turf sports that involve planting of the foot and cutting
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10
Q

High Ankle Sprain

Clinical Presentation

A
  • Pain localized to AITFL
  • TTP of the AITFL
  • Pain w/ active or passive ER of foot
    • ​DF+EVERSION TEST
  • Pain w/ active or passive forced DF
    • ​DF+EVERSION TEST
  • May have heel-rise gait pattern to AVOID excess. ankle DF/pain
  • Antalgic gait w/ shortened stance phase on injured LE
  • SEVERE swelling is RARE
  • MAY be accompanied by deltoid (med.) lig sprain + Fibular Fx
  • (+) Squeeze Test
    • ​compressing tib/fib together
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11
Q

Squeeze Test for High Ankle Sprain

A
  • pt lies SUPINE or seated w/ leg off edge of table
  • examiner grasps lower leg at midcalf and squeezes tib/fib together
  • (+) if proximal force** causes **distal pain near syndesmosis
    • ​bc Distraction force caused @ distal end when you squeeze PROXIMALLY
  • Sn= .30 (70% FN’s) Sp= .93 (7% FP’s)
  • +LR= 4.60 (want >10) -LR= .75 (want
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12
Q

High Ankle Sprain

Interventions

A
  • Conservative Tx in the absence of fx (Sx for severe cases)
    • ​RICE
    • IMMED. NWB to prevent further injury;
      • progress to WB as pain allows
    • splint/brace/tape for mech. stability as needed
    • GRADUAL progress. of AROM as pain allows
    • GRADUAL progress of strengthening as pain allows
    • GRADUAL progression of balance/proprio training as pain allows
    • Gait training—–include AD if necessary
    • Restore FXN, and return to sport/rec.
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13
Q

Medial (Deltoid Lig.) Ankle Sprain

RARE****

MOI:

A
  • Injury to Deltoid Lig.
  • MOI:
    • ​Eversion of ankle
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14
Q

Medial Ankle Sprain

Eversion Sprain

Clinical Presentation:

A
  • sig. swelling
  • tenderness over medial ankle
  • ecchymosis over medial ankle
  • Pain localized to medial ankle w/ valgus stress
  • INTERVENTION:
    • ​similar to Lat. Ankle Sprain
      • BUT direction of motion to protect is Eversion
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15
Q

Chronic Ankle Instability

A

Recurrent ankle sprains AND repetitive episodes of giving way

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16
Q

Chronic Ankle Instability

Risk Factors

A
  • INCd talar curvature
  • NOT using ext. support
  • NOT performing balance or proprio. ex’s following acute lateral ankle sprain
  • Previous ankle sprain
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17
Q

Chronic Ankle Instability

Clinical Presentation:

A
  • Hx of repeated ankle sprains/giving way
  • Persistent pain
  • DECd postural control
  • INCd instability
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18
Q

Chronic Ankle Instability

Intervention

Non-OP vs

Surgical

A
  • NON-OP—-similar to Lat. Ankle Sprain w/ emphasis on balance training
  • Surgical:
    • ​Lat. Ankle Repair
      • _​_remember “REPAIR” is much less stable and you MUST BE MORE CAREFUL
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19
Q

Lateral Ankle Repair

Indications:

A
  • Chronic ankle sprains or instability
    • elective sx
    • usually those under 40 and athletic
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20
Q

Lateral Ankle Repair

Gen. Sx Procedure

A
  • Lat. incision made to access ATFL/CFL
  • Ligs overlapped and sutured (BE CAREFUL W/ THESE!!!)
  • **First 6 wks MOST important AND vulnerable time for healing repair
    • ​AVOID:
      • ​Inversion & PF
        • ​why????
          • ​bc THIS IS THE MOI!!!!!
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21
Q

Recommended Interventions during Acute/Protected Motion Phase

A
  • EXT. support and progressive WB (AD as needed)
  • Manual therapy
    • soft tissue mobs+jt. mobs
      • ​INCLUDING post. talar glide (for DF)
  • Cryotherapy
  • TherEX
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22
Q

Recommended Interventions during Subacute/Chronic Progressive Loading/Sensorimotor Traning Phase

A
  • Manual Therapy
    • Jt mobs, MWM to improve DF ROM, proprio and WB tolerance
  • TherEX, functional+balance activities
  • Sports related act. training
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23
Q

Ottawa Ankle Rules

A

*developed to det. need for radiographs after acute ankle injury 2* to risk of Fx

  • Sn= 96.4-99% (+ Fx)
    • ​IF they test NEGATIVE—-most likely NEGATIVE!!!
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24
Q

Ottawa Ankle Rules

Ankle X-Ray Series Req’d

Criteria:

A
  • Any pain in Malleolar Zone AND:
      1. Bone tenderness @ Post. edge OR tip of Lat. Malleolus
      1. Bone tenderness @ Post edge OR tip of Med. Malleolus
      1. Inability to bear wt BOTH immed AND in ED
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25
Ottawa Ankle Rules **_Foot_** **X-Ray series req'd:** **Criteria:**
* Any pain in **_Midfoot Zone_** AND: * 1. Bone tenderness @ **Base of 5th Met.** * 2. Bone tenderness @ **Navicular** * 3. **Inability to WB BOTH immed. AND in the ED**
26
Ankle ORIF **PT _usually initiated_** **When?**
~6 weeks
27
Ankle ORIF ## Footnote **6-8 wks**
* RICE * **Submax** iso's * Proprio * PROM/AROM * Bike * STM * **Progressive** WBAT * **Jt mobs @ 8 wks\*\*\*\*\***
28
Ankle ORIF **9-12 wks**
* Isotonic (conc/ecc.) bands * TM * Bike * Stairs * CKC (closed-kinetic chain) ex's * Balance boards * **INC jt. mobs Grade**
29
Ankle ORIF: **13-18 weeks**
* Cont. **phase 1 & 2 goals+interventions** * Add **incline/decline** walking, plyo's, agility, **more aggressive strengthening**
30
Ankle ORIF **19+ weeks**
RETURN TO WORK/SPORT TRAINING!!!
31
Ankle Fx **W/OUT Sx**
* **WB Status ------depends on physician/surgeon** * **​**OFTEN **limtd--**PWB or NWB **6-8wks----Immobilized** * **​**clarify if unsure * **Casted JUST BELOW FIBULUAR HEAD (common peroneal nerve wraps around fib. head) 3-4wks** * **​THEN progressed to Cam (Controlled Ankle walker)** * often NOT referred to PT **EARLY in Post-OP phase** * **​**depends on managing physician's preference
32
Ankle Fx W/OUT Sx ## Footnote **First 6-8 weeks** **During Immobilization**
* Crutch OR walker training (with stairs) * NOTE: ONLY 2 (crutches/SW) things you can use w/ **WB restrictions!!!** * Progress WB and gait **as tolerated/per physician orders** * hygiene, toe wiggling, **AROM of other jts of LE (OKC ex's for other mm's)** * **Strengthen ALL other accessible mm's** * **​OKC ex's** * \*\*obtain clearance for **bicycle** to **maint. aerobic capacity**
33
Ankle Fx W/OUT Sx **6-12 weeks OR 8-12 weeks:**
* Progress to **FULL WB** AND **normalize Gait ----TM training** * Normalize **jt mobility (\*\*will be restricted)** * Normalize **ROM** * **​stretching+PROM** * Progress **strength** to **FULL** * Work on **balance + proprio**
34
Ankle Fx W/OUT Sx ## Footnote **12-18 weeks:**
* plyo's * agility * **Jog/Run** * **Return to work/sport cond'ing** **\*\*NOTE:** once Cast is OFF an **WB restricts removed----**pt can progress thru all of these activities as tolerated
35
Osteochondritis Dissecans of the Talus is **usually:**
SUPRAMEDIAL
36
Osteochondritis Dissecans of the **Talus** **\*part of _Subchondral bone_** **has come OFF** **Etiology:**
* **Repetitive micro-trauma, vascular failure, _genetic predisposition_** * NON-traumatic lesion **often assoc'd w/ HIGH act. lvl in the _child or ado._** * Lesion typ. **superomedial Talus \*\*\*\*\*\*\***
37
Osteochondritis Dissecans of the Talus **Clinical Presentation:**
* pain, swelling, popping, clicking, locking, **stiffness** * **Point tenderness-------SUPRAMEDIAL TALAR PAIN \*\*\*\***
38
Osteochondritis Dissecans of the Talus ## Footnote **Intervention:**
* Cast * Immobilization * **Protected WB FIRST\*\*\*** * Sx IF conservative Tx fails
39
Osteochondral **_LESION/_**Osteochondral Fx of the Talus NOT OSTEOCHONDRITIS DISSECANS **ACTUALLY INJURY TO _CARTILAGE_** _Usually **where?**_
**SUPEROLATERAL** Osteo dissecans is **superoMED.**
40
Osteochondral **_Lesion/_Osteochondral FRACTURE of the Talus** ## Footnote **Etiology:**
* **Traumatic** lesion often assoc'd w/ **ankle sprain** w/ the **Foot in INVERSION** * 2nd thru 4th decade * **Lesion typ. SUPEROLATERAL talus**
41
Osteochondral Lesion/Osteochondral FRACTURE of Talus ## Footnote **Clinical Presentation:**
* MORE ANT. SX'S----**ESP IN PF** * ​pain * swelling * popping, click, locking * stiffness * **point tenderness------more ant. esp in PF**\*\*\*
42
Osteochondral Lesion/Osteochondral FRACTURE of Talus ## Footnote **Interventions:**
* **Sx-----MORE effective in ADULTS \*\*\*\***
43
Talar Dome Fx pain/sx's MORE\_\_\_\_\_\_\_
POSTERIOR
44
Talar Dome Fx ## Footnote **Etiology** **Presentation** **Interventions**
SIMILAR to **Osteochondral defects of Talus** ## Footnote **which you already KNOW/COVERED!!!**
45
Talar Dome Fx ## Footnote **LATERAL Dome Fx's almost ALWAYS assoc'd w/\_\_\_\_\_\_\_\_\_\_\_**
TR**A**UM**A**!!!!!! LAT has A's.......Trauma has A's------REMEMBER IT THIS WAY!!!
46
Talar Dome Fx ## Footnote **MEDIAL Talar Dome lesion can be _______ OR \_\_\_\_\_\_\_**
Atraumatic OR Traumatic (**Medial likes BOTH!!!)**
47
Tuberosity Avulsion Fx (sharpey's fibers SO strong that the **bone actually fx's first)** ## Footnote **\*different from Jones Fx** **MOST COMMON Fx involving\_\_\_\_\_\_\_\_**
* 5th Metatarsal
48
Most common Fx involving 5th Metatarsal
Tuberosity Avulsion Fx
49
Tuberosity Avulsion Fx ## Footnote **MOI:**
* typ. occurs AFTER **forced INversion** w/ foot and ankle in **PF** FROM **pull by lat. band of _plantar fascia OR fibularis brevis_**
50
Tuberosity Avulsion Fx **Clinical Presentation:** **Intervention:**
* Sudden onset of pain @ **base of 5th MET** * pain w/ **WB** * Tenderness @ **base of 5th MET** * Ecchymosis * Swelling **INTERVENTION==\>** WBAT
51
Jones Fx ## Footnote **DIFFERENT VS. \_\_\_\_\_\_-**
Tuberosity Avulsion Fx
52
HOW is Jones Fx different vs. Tuberosity Avulsion Fx?
* Jones Fx * fx's of **prox. 5th MET--DISTAL to the tuberosity w/in 1.5cm of the base area** * **Usually HORIZ. and NON-Displaced\*\*\*\*\***
53
Jones Fx ## Footnote **MOI:**
* **Laterally directed---**INVERSION **twisting** of the foot OR **fall from standing ht.** * **​Prone to NON-Union** * **​usually req's Sx \*\*\***
54
Jones Fx **Clinical Presentation:**
* Sudden pain @ **base of 5th MET** * **Diff. WB** * Ecchymosis, Edema
55
Jones Fx ## Footnote **Intervention**
* usually **surgical** * **​**intramedullary nails/screws fixation\*\*\*\*
56
5th MET Fx's ## Footnote **Differentiating:**
see pics
57
Almost ALL _______ can be Tx'd the EXACT SAME WAY
Tendiopathies!!! **\*_Relative rest_ to DEC aggravating activity**
58
Achilles Tendinopathy ## Footnote **Etiology + Explain diff. b/w Mid-Portion and Insertional Achilles Tendinopathy**
* Etiology: * **overuse** related to **repetitive microtrauma (**excess **compression** or **tensile load** or **BOTH)** * **Mid-Portion** * **​MOST COMMON** * **​**Can get MORE DF with mid-portion * have them do full ROM (standing on a step) heel raises * **Insertional** * **​actually @ the insertion of the Achilles tendon** * **ONLY DO THINGS FROM FLOOR**
59
Achilles Tendinopathy ## Footnote **INtrinsic Risk Factors:**
* AGE * 41-60yo * High BMI * Kinesiophobia * **DECd ankle PF strength** * **abnormal tendon structure** * **Co-Morbidities: Corticosteroid Use!!! (use sparingly)** * **​**Fluoroquinolone use, Statins, HTN * Hyperlipidemia, Diabetes
60
Achilles Tendinopathy ## Footnote **EXtrinsic Risk Factors**
* **Training Errors!!!** * **​**Abnorm. mvmt patterns, * excessive mileage * RAPID INC in mileage * hill training
61
Achilles Tendinopathy **Clinical Presentation:**
* MALE * 30-50yo * **Localized pain + perceived stiffness in Achilles** **_following a period of inactivity,_** LESSENS w/ an acute bout of activity (bc you're warm), **and may INC after the activity (bc you're cooled off)** * Achilles tendon tenderness * **insertion point OR more commonly 6cm proximal---(mid portion)** * DECd **PF strength, endurance** * Pain w/ **contraction or stretch** of Gastroc/Soleus complex * Pain w/ **push off, walking UPhill, toe walking** * **\*\*If TRAUMATIC, SEVERE, UNRESPONSIVE to interventions===\> MRI to R/O Achilles tear**
62
Dx and Classification of Achilles Tendinopathy
* **Arc Sign--\>** area of palpated swelling MOVES w/ DF and PF * **Royal London Hospital Test:** * (+) when **tenderness** occurs **3cm** prox to **calcaneus** w/ ankle in **slight PF,** that DECs as **ankle is DF** * Pt reports pain **located 2-6cm prox to Achilles insertion-------**began gradually * Pain w/ palpation of **midportion** of the tendon to Dx **midportion Achilles tendinopathy**
63
Swelling in ONE spot while tendon moves
Tenosynovitis
64
Three Options often available to the PT when treating a pt
1. Treat 2. Treat and Refer 3. Refer
65
CPG Decision Tree ## Footnote **Component 1: Medical Screening** **Component 2: Classify Condition (includes Pt Exam)** **Component 3: Determination of Irritability Stage**
* Eval and see if approp for PT * classify cond. * Pt exam * PT Dx or Diff Dx * Determine irritability!!!
66
CPG Decision Tree ## Footnote **Component 4: Outcome Measures** **Looking @ tests**
* Measures to assess **lvl of functioning,** **presence of assoc'd phys. impairments to address w/ tx, response to tx.**
67
A Note about **Outcome Measures** ## Footnote **Region Specific vs. Condition Specific**
* **Region Specific** * **​**FAAM or LEFS (LE function) * **specific to foot AND ankle** * **taking a more regional approach** * **Condition Specific** * ​VISA-A is **for Achilles tendinopathy** * **​specific to THE CONDITION of Achilles tendinopathy** * **zoning in on that ONE thing!!!**
68
CPG Decision Tree ## Footnote **Component 5: Intervention Strategies** **\*Irritability\***
* Acute vs. NON-Acute **Dx Indicators**
69
CPG Decision Tree ## Footnote **Re-Evaluate**
* Pt goals **Met vs. NOT improving**
70
NOTE: When treating a patient..... \***REMEMBER THIS!!!**
If you do not make them **more symptomatic @ some point (or REALLY push their limits)......you are probably not pushing them hard enough!!!** **\*do this @ least once so you set a _boundary!!!_**
71
Achilles Tendinopathy ## Footnote **Interventions:**
* Reduce **aggravating factors** * **​**_gradually_ Re-load tendon to **tolerance** * **Complete rest NOT INDICATED;** Cont. activity to **tolerance** * **Eccentric loading OR heavy load, slow speed (conc/ecc.) ex. program for Gastroc/Soleus complex** * Stretching of **ankle PF's** * w/ knee flexed (soleus) * w/ knee extended (gastroc + soleus) * **\*only if limtd ankle DF ROM/flex found on exam** * NMSK re-ed. **targeting LE impairments that INC load on Achilles** * Manual therapy----**jt mobs and STM** * **Modalities:** * **​**Iontophoresis w/ **dexamethosone** * **​low lvl laser therapy evidence contradictory-----NOT GREAT** * **RIGID (not elastic) taping** * **Progressive return to PLOF and activity** * **\*\*\*Contradictory evidence for heel lifts and orthoses\*** * **​Night Splints NOT RECOMMENDED!!!**
72
MOST COMMONLY RUPTURED TENDON
Achilles Tendon Rupture
73
Achilles Tendon Rupture
* MOST commonly ruptured tendon! * **degen changes (tendinosis) in tendon present from _overload due to repetitive microtrauma_**
74
Achilles Tendon Rupture ## Footnote **MOI:**
* **Push off** in **knee EXT.** * **​**sprinting/jumping * Sudden **DF** in **full WB** * **​**fall, trip UP steps * Landing on **PF foot** from a **height**
75
Achilles Tendon Rupture ## Footnote **Risk Factors**
* Sports * Males\*\*\* * 30-40yo * **Box jumps the wrong way!!!**
76
Achilles Tendon Rupture **Clinical Presentation**
* Assoc'd w/ **sudden pain, inability to WB, weakness of _affected ankle_** * _(+)_ **Thompson Test** * DECd **ankle PF strength** * **Palpable gap**
77
Achilles Tendon Rupture ## Footnote **Interventions:**
**Sx repair** is **favored** to **minimize risk of re-rupture**
78
Thompson Test **For Achilles Rupture** **The "Squeeze calf" one...** **if (+)=== probably torn** **if (-)=== probably NOT torn**
* Tests for **Achilles Tendon Rupture** * pt lies PRONE * squeeze calf * **(+) Test=** ABSENCE of PF when mm is squeezed ## Footnote **Sn= .96 (4% FN's)** **Sp= .93 (7% FP's)** **+LR= 13.47 (strong, want \>10)** **-LR= .04 (strong, want**
79
Achilles Tendon Repair ## Footnote **Traditional rehab models vs. Early motion models**
\*we are now MORE @ **early motion models** * Commonalities: * **Protection of the repair EARLY ON w/:** * **​Protected** WB----- 4-8wks * AVOIDANCE of **excess. ankle DF ROM** * AVOIDANCE of **resisted ankle PF**
80
Fibular (Peroneal) Tendinopathy \*think **Lateral Everything!!!\*** **Etiology:**
* trauma from **Lateral Ankle Sprain OR** overuse related to **repetitive microtrauma**
81
Fibular (Peroneal) Tendinopathy ## Footnote **Clinical Presentation:** **\*think LATERAL foot and Supinated (rigid) foot**
* Pain **post OR dist. to lateral malleolus** * Pain @ **fib. longus/brevis path or insertion** * POSITIVE **resisted iso. testing of _Eversion in PF_** * Pain w/ **Passive stretch into** **_Inversion_** * Pain w/ **_terminal stance_** * **Unilateral heel rise** painful * Pain w/ **fig. 8 walk OR walking on sides of feet (in constant INversion)**
82
Fibular (Peroneal) Tendinopathy ## Footnote **Risk Factors**
* Pes Cavus (like a cave)= **high arch** * Rearfoot Varus/Forefoot Varus/**Excessive supination** * **​== Rigid Foot** * **INCd training or act. involving repetitive and/or high power** **_toe off w/ lateral motion_**
83
Fibular (Peroneal) Tendinopathy ## Footnote **Interventions:**
SAME as other tendinopathies
84
Tom, Dick, Harry ## Footnote **all go past what?**
ALL pass through **medial malleolus**
85
Posterior Tibialis Tendinopathy ## Footnote **\*Think MEDIAL foot!!!\*** **Etiology:**
* OVERUSE related to **repetitive microtrauma**
86
Posterior Tib. Tendinopathy ## Footnote **\*\*think MEDIAL FOOT, think PRONATED (flat) foot!!!\*** **Risk Factors:**
* FEMALE * \>40yo * **Pronated foot----Pes Planus** * Obesity * **excess walking, running, standing, stairs** * \*\*\***Can lead to PTSS (post. tib stress syndrome) AND adult onset flat foot** * **​PTSS---\> mm pulls on medial border tibia**
87
**Post Tib. Tendinopathy** **\*\*Think MEDIAL foot, think Flat foot, think pain trying to CREATE an arch!!!\*** **Clinical Presentation:**
* Pain and swelling **post. to MEDIAL malleolus** * Pain WORSE w/ **WB** * Pain/weakness w/ **resisted iso. INVERSION/PF** * Pain/weakness w/ **resisted Forefoot ADDuction** * **"**Too many Toes sign"---- very ER foot * Pain w/ S/L heel raise OR **inability to perform S/L heel raise** * **Lacks normal INversion when rising up on toes\*\*\*\*\*** * **​compare sides** * Ache after walking long distances * Pain w/ **stretch of Post. Tib**
88
Post. Tib. Tendinopathy vs. Flexor Hallucis Longus Tendinopathy ## Footnote **Differentiating?**
FHL Tendinopathy would cause **pain in GREAT TOE bc inserts there !**
89
Too many toes sign:
see pics ## Footnote **note: calcaneal valgus**
90
Post Tib Tendinopathy ## Footnote **Interventions:**
* NO DIFF. vs. other tendinopathies * Reduce **aggravating factors,** _Gradually reload tendons_ * RICE during **acute phase** * **Initial use of brace** to UNLOAD tendons, **followed by transition to in-shoe orthotic** * **PREs----ECC. ex's preferred\*\*\*** * **​**Slow, controlled loading of tendon is idea * **Stretching** in **neut. foot pos.** * Progress to **functional acts.**
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Medial Tibial Stress Syndrome AKA
"True Shin Splints"
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Medial Tibial Stress Syndrome aka **True Shin Splints** **Pain along\_\_\_\_\_\_\_\_\_\_\_\_**
* Pain along **Posteromedial border of tibia DURING EXERCISE** ------\*Excludes **compartment syndrome & stress fx**
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Medial Tibial Stress Syndrome aka **True Shin Splints** **Theories on Cause?**
* Differing Theories: * **Thought** to be **chronic periosteal inflammation** due to **pull of mm's on tibia**
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Medial Tibial Stress syndrome aka True Shin Splints **Risk Factors**
* athletes who part. in **intense, repetitive WB acts.** * Training errors * Biomech. Abnorms: * **INC pronation** * **INC hip ER/IR** * FEMALES * higher BMI * **Prev. LE injury** * **​hx stress fx's, hx of MTSS**
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MTSS True Shin Splints **Clinical Present:**
* **Exercise induced** leg pain along **posteromedial border of Tibia** * **​\*\*\*anterolat is more Ant. Tib Tendinopathy\*\*\*** * Pain w/ **initiation of act.** that **subsides w/ cont'd ex** BUT RETURNS LATER **during act.** * Pain w/ palpation of **dist. 2/3 posteromedial tibial border spread over @ least 5 cm**
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MTSS True Shin Splints ## Footnote **Interventions:**
* Relative rest * not really rest, "Active rest" * Ice, NSAIDs * **Modify source of rep. stress** * **​**can be hard/uneven surfs, duration/intensity/freq of training * Approp **footwear** * **​support+shock absorb.** * **Orthotics** to correct **overpronation** * Stretch/strengthen **as tolerated** * **_Progressive, gradual_** return to running/sport * \*\*\***Often EARLY return to running/activity OR inad. rest DELAYS HEALING** * **​**Feel better so try to return TOO quickly!!!
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Chronic Exertional Compartment Syndrome
* **Lower leg pain** DURING EXERCISE due to **INC in tissue pressure** w/in the **confinement of a closed fascial space**
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Chronic Exertional Compartment Syndrome ## Footnote **MM volume can inc up to 20% of its resting size during ex...... how does this cause or exacerbate CECS**
* INC in **internal pressure** w/in **fascial compartment**
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Chronic Exertional Compartment Syndrome ## Footnote **5 Osteofascial Compartments:**
* 1. Anterior * 2. Lateral * 3. Superficial Posterior * 4. Deep Posterior * 5. Posterior Tibialis
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Chronic Exertional Compartment Syndrome ## Footnote **\_\_\_\_\_\_\_\_\_compartment MOST COMMON site**
Anterior Compartment **most common**
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Chronic Exertional Compartment Syndrome **Clinical Presentation:**
* **Development of pain:** * **​**SAME **time, distance, intensity of exercise (you notice it comes on @ predictable time)** * INCs w/ **continuation of ex.** * Resolves after **rest pd.** * Pain---\> burning, aching, pressure * N/T (numb/tingling) **in distribution of nerve running thru compartment** * Pain on palpation of **mm's involved** * Pain w/ **passive stretch of mm** * **Firmness** of **involved compartments**
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Chronic Exertional Compartment Syndrome ## Footnote **Clinical Presentation** **WEAKNESS (and weakness of specific motion and what that means)**
* Weakness of **affected mm:** * **​**Weakness of **DF==\>** ANT. compartment * Weakness of **Eversion==\>** LAT. compartment * Weakness of **PF==\>** POST. compartment
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Chronic Exertional Compartment Syndrome ## Footnote **Interventions:** **Sx vs. NON-OP**
* **Sx:** * Fasciotomy (cut into fascia to releive pressure) * **only definitive intervention\*** * **Non-OP (emerging/litte evidence)** * **​**Relative rest * Ice, anti-inflamms * **Stretching** of **involvd mm's** * AVOID **running on hard surfs., change footwear, and biomechs of running** * **Orthotics** * Soft-tissue tech's
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Exertional Compartment Syndrome vs. Shin Splints (Medial Tibial Stress Syndrome) ----more **posteromedial tibia**
see chart
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W/ **Stress Fx's** ## Footnote **MOST common location?**
Tibial Shaft
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Stress Fx's ## Footnote **Tibial shaft MOST COMMON** **Etiology?**
* result of **excess repetitive stress** * **​**bone mineral **resorption** EXCEEDS **deposition** * **​==\> Fatigue Fx**
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Stress Fx ## Footnote **Tibial shaft MOST common** **INtrinsic Risk Factors:**
* Poor phys. conditioning * FEMALES * Hormonal disorder * DECd **bone density** * DECd **mm mass**
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Stress Fx's ## Footnote **EXtrinsic Risk Factors**
* Running/jumping sports * **Rapid INC** in training * Running on **uneven surfs.** * Poor **footwear** * **Old** running shoes: * \>6mos or 300mi. * Poor nutrition--\> **DECs bone health** * Vit. D/Calcium * Smoking--\> **DECs bone health**
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Stress Fx's ## Footnote **Clinical Presentation**
* Onset of pain is **gradual** * **Initially--** pain ONLY while running/during act. and Pain **DECs w/ rest** * **Later---** pain may **persist after exercise** and occur **during daily activities** * **Focal pain----\>** not to be confused w/ Comparment syndrome * X-ray usually **not positive until 2-8wks of sx's** * **MRI, CT MORE Sn early on**
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Stress Fx ## Footnote **Interventions:**
* Relative rest * **Shock absorbing insoles** may have role in **prevention**
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Acute Comparment Syndrome ## Footnote **Medical Emergency!!!!** **what is it?**
* SAME as exertional compartment syndrome BUT **rapid inc's in Vol. from TRUAMA!** * Result of **swelling or inflamm (usually from Trauma)** that causes INC pressure in closed fascial compartments containing **mm's, nerves, vascular supply** * **\*\*MEDICAL EMERGENCY!!!**
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ACUTE Compartment Syndrome ## Footnote **As pressure INCs....**
* mm and nerve function **impaired** AND **necrosis** of soft tissue develops------**w/in 3 hrs**
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Acute Compartment Syndrome **Clinical Presentation: "4 P's"** **(Griffiths, 1948)**
1. **P**ain (severe AND spontaneous; **earliest and MOST SENSITIVE sign)** 2. **P**arasthesia/numbness 3. **P**aresis 4. **P**ain w/ stretch \***Also DECd/Absent pulses** **\*Pink skin color** **EMERGENCY----call physician & send to ER!!! \*\*\*\***
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Acute Compartment Syndrome ## Footnote **Interventions:** **MEDICAL EMERGECNY!!!**
* **Fasciotomy** of **involved compart.** **​**
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Plantar Fasciitis **Etiology:**
* Overuse syndrome **of the origin of the Plantar Fascia** * **​Heel bone!!!** * **Repetitive loading of the _central band of the plantar fascia_** develops INTO **fasciopathy**
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Plantar Fasciitis ## Footnote **Risk Factors:**
* 45-64 yo * Obesity (INCd BMI) * DECd **ankle DF ROM** bc now you use **more Pronation** * Job req'ing prolonged time on feet * **Recent** INC in running * Flat feet OR High arched feet
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Plantar Fasciitis **Clinical Presentation:**
* Pain in **HEEL** * **​**moreso**===\>** **Medial Calcaneal Tubercle** * **​classic sign** * Insidious onset * Pain and diff. walking **first thing in the morning OR after pd of NWB** * **​==\> Post-Static Dyskinesia** (exactly waht it sounds like!!!) * Pain **gradually** improves @ first **w/ activity,** but **worsens** w/ **prolonged act.** * Pain w/ DF/EXT of 1st MTP * == **Windlass Mech.** * **Sharp** pain to palpation @ **heel/PF insertion** * Antalgic Gait: * pain w/ Full WB, **esp on foot flat and DF** (bc now plantar fascia stretched) * MAY **walk on sides of feet** to **avoid stretching** plantar fascia that occurs during **pronation** * Contractile Testing: * **strong & pain-free** * **​\***bc plantar fascia is **inert** **tissue---\>** NOT part of MTU
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Plantar Fasciitis ## Footnote **What is often present (in the foot)?**
* Pes Cavus OR Pes Planus **often present** * **​****Pes Planus==Excess Pronation==PF _always_****getting _overstretched_** * **Pes Cavus==Supination==PF is short/tight _and does NOT lengthen adequately during WB_**
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Plantar Fasciitis and X-ray
* X-ray **may or may not** show **heel spur** on the **medial tuberosity of the calcaneus**
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Tests for **Plantar Fasciitis**
Windlass Test Passive 1st MTPJ EXT.
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Windlass Test Passive 1st MTPJ EXT
* tests for **plantar fasciitis** * knee 90deg. flexion * can be WB or NWB * stabilize ankle in neut, grasp prox. segment of hallux w/ other hand * IP jt **is allowed to flex** so the FHL mm does not restrict motion * **First MTPJ is passively DF to end range OR until subj feels pain** * **(+) if test repro's pts specific pain** * **Sn= 13.6% (87% FN's)** * **Sp=100% -- NO FP's----if (+), its there!!!**
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SnNOUT SpPIN
* SnNOUT * Negative result on HIGHLY SENSITIVE test rules OUT * SpPIN * Positive result on HIGHLY SPECIFIC test rules IN
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Interventions to Directly Address Plantar Fascia-related Phys Impairs:
* TherEX * Stretching: * plantar fascia---(fig. 4--\> pull up on all toes in DF), gastroc, soleus * Manual Therapy * Jt mobs LE, **emphasis on improving talocrural DF** * STM plantar fascia, gastroc, soleus myofascia * Anti**pronation** taping * Foot orthoses * **prefab OR custom orthoses to support _medial arch_** **and _cushion heel_** * Heel cushion, footwear and/or **orthotics w/ heel cushioning** * **Pt ed.** * **​**Strats. to modify WB loads during work/daily acts * footwear to mitigate WB stresses * strats to achieve/maint. optimal wt. * **Night splints 1-3mos** * **​keeps you IN DF** * Modals: * Iontophoresis, low lvl laser, phonophoresis
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Elevating the heel for plantar fasciitis during squats
Greater excursion of DF Plantar fascia is now on LESS of a stretch
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Interventions to Address Lower-limb Phys Impairments **Potentially Assoc'd w/ Plantar Fasciitis** ## Footnote **Manual Therapy**
* Manual therapy: * Jt mobs AND manual stretching to restore **normal 1st MTPJ, tarsometatarsal jts, talocalcaneal, talocrural, knee & hip mobility** * STM+manual stretching to restore **normal mm length of calf, thigh, & hip myofascia that are req'd @ _Terminal Stance_****​**
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Interventions to Address Lower-limb Phys. Impairments Pot. Assoc'd w/ Plantar Fasciitis ## Footnote **TherEX and Neuromuscular Re-Ed**
* Strengthen/training mm's that work **eccentrically** to control **pronatory tendencies (**remember **P.DEAB)** and improve **ability to attenuate/absorb WB forces** * **​**1. Mid-tarsal Pronation== **Post. Tib and Fib. Longus work ecc.** * 2. Ankle PF== **Ant. Tib works ecc.** * 3. Knee flexion==**Quads work ecc.** * 4. Hip ADD.== **Glute med works ecc.** * 5. Lower Limb IR==**hip ER work ecc @ LR to lessen**
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Pro-Stretch
just remember to associate this w/ **Plantar Fasciitis**
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Tarsal Tunnel Syndrome
Immediately you think Neurological sx's !!! N/T Sensory impairs!!!!!!!
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Tarsal Tunnel Syndrome **Etiology:**
* **Focal, compressive** _neuropathy_ of the **post. tibial nerve OR one of its assoc'd branches**
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Tarsal Tunnel Syndrome ## Footnote **Contents of Tarsal Tunnel** **from AnteroMed to PosteroLat:**
**Tom, Dick And Very Nervous Harry** * Tib Post * FDL * Post. Tibial Artery * Post. Tibial Nerve * FHL see pic but don't forget "Very" ---vein !
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Tarsal Tunnel Syndrome ## Footnote **Risk Factors**
* sports * obesity * **Foot deformities** * **​pes planus** * **​bc now stretching out Tom, Dick, Harry tendons and nerve** * DM, trauma, inflammation TO area * prolooonged standing, walking, new exercise
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Tarsal Tunnel Syndrome **Clinical Presentation:**
* Pain **behind Medial Malleolus region** * **Sensory disturbs** in _Tibial nerve distribution:_ * _​_**retromalleolar**, **sole,** **heel** **OR digits** * **pain, numb, parasthesias** * Intrinsic weakness * **Clawing of toes** * **​when prolonged** * Postive **Tinel's Sign** * **​Bang on the Door!** * Repro of sx's w/ **passive ankle DF w/ Eversion** * **​**WORSE w/ prolonged **walking**
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Tinel's Sign for Tarsal Tunnel Syndrome **Bang on the Door!** **Where?**
* Over **Posteromedial aspect of the ankle** * **(+) Test= repro of pts sx's/tingling or parasthesias felt DISTALLY**
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Tarsal Tunnel Syndrome ## Footnote **Interventions:**
* RICE 24-48 hrs * remember **Relative Rest** * REMOVE **aggravating act.** * **Nerve gliding** * Orthotics **if indicated** * MM stretching * Mm strengthening * STM in **late or chronic stage of rehab** * **US commonly used BUT NO EVIDENCE** * **Correct impairments and address act. limits.**
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Morton's Neuroma ## Footnote **Whats unique about this?**
NOT REALLY A NEUROMA!!!
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Morton's Neuroma
* **Not actually a neuroma!** * **​**It is a **thickening of the tissue that _surrounds the digital nerve leading to the toes._** * **_​_**occurs as nerve passes UNDER IMT lig **connecting the Metatarsals** * **​\*often b/w 3rd and 4th digits** * **​\*3rd webspace!!!\***
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Morton's Neuroma **Etiology:**
* Result of **stress+irritation** to the nerve * due to **excess. toe DF \*\*\***
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Morton's Neuroma ## Footnote **Risk Factors:**
* 8-10x MORE COMMON in **Women** * **​bc of footwear**
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Morton's Neuroma **Clinical Presentation:**
* Mean age: 45-50 * **Sharp/burning pain** * **numbness or feeling of a rock in your shoe @ balls of feet**
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Morton's Neuroma **Interventions:**
* Shoe modification * **NO high heels or narrow toes** * **orthotics** * **pad that elevates MT head on _medial side_** * **cortisone inj's** * **Sx resection ==== last resort**
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Morton's Neuroma ## Footnote **Thumb Index Finger Squeeze Test** **\*exactly what it sounds like!**
* SUPINE * **Symptomatic intermetatarsal space** is squeezed b/w **tips of index finger (dorsal foot) and thumb (plantar foot)** * **_Splaying of toes_**===\> **indicates** **correct positioning of fingers and pressure applied** * **(+) Test= pain repro'd** * **Sn= 96%, Sp= 100%** * **PPV= 100%, NPV= 33%**
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Hallux Rigidus/Limitus
**Limitus==Early stages** **Rigidus==When motion MAXIMALLY restricted/absent**
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Hallux Rigidus (late)/Limitus (Early) ## Footnote **what is it?**
* Progressive restriction of motion **in 1st MTPJ** * **​ESP into EXT!!!**
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Hallux Rigidus/Limitus ## Footnote **Etiology:**
* Progressive **degenerative arthritis of 1st MTPJ** * May be **trauma, cumulative micro-trauma, RA or gout**
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Hallux Rigidus (late)/Limitus (early) ## Footnote **Risk factors:**
FEMALES
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Hallux Limitus (early)/Rigidus (late) ## Footnote **Clinical Present:**
* Pain @ **1st MTPJ** * Loss of **1st MTPJ EXT. and later.....FLEX** * **DECd _toe off,_** **diff w/ heel rise and squat**
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Hallux Limitus/Rigidus ## Footnote **Intervention:**
* LIMIT 1st MTPJ motion to **protect and remove** irritating stress on joint * taping, shoe orthotics * Manual therapy (jt mobs) to improve 1st MTPJ motion * **stiff soled, deep toebox shoes** * **Sx:** * **​**Cheilectomy * **removes bone spurs** * Prox. Phalanx Osteotomy * **change pos. of bone** * Arthrodesis * **alterations and fusions**
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Hallux Valgus and Bunions
* "Valgus"==\> angle of 1st MTP * **Hallux moves LAT.** **relative to metatarsal** * **​up to 20o is common** * **\>20-30o==\> hallux valgus** * **"Bunions" ==\>** resultant callous formation, **thickened bursa,** & **bony exostosis on MED. side of 1st MTP**
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Hallux Valgus and Bunions ## Footnote **Risk Factors**
* Hereditary, **abnorm foot mech's, high heels, narrow toed shoes, MAY BE RELATED** to gout/RA * Women\>Men
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Hallux Valgus and Bunions ## Footnote **Interventions:**
* Toe spacers, **splinting,** adaptive footwear, **orthotics for correction of foot align.** * Strengthening ex's * **current evidence suggests progression w/out sx correction**
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Bunionectomy ## Footnote **Takeaway: if fusion--\> DO NOT TRY TO MOBILIZE A FUSED JOINT!!!**
* Over 100 sx procedures for **bunions**----little evidence to say one is better than other * **Gen types:** * **​**Exostectomy * removal of part of metatarsal head * Realign. of soft tissues around 1st MTPJ * Metatarsal Osteotomy * removal of sm. wedge of bone * Resection Arthroplasty * MTPJ bones reshaped * Arthrodesis (**fusion**) * fusion of MTPJ * Lapidus procedure * fusion of midfoot * Implant insertion of ALL or PART of an **artificial joint**
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Bunionectomy ## Footnote **From a PT perspective....**
MOST IMPORTANT THING... * Pay attn to IF and WHAT jts were **Fused** * **​**Otherwise....**might end up trying to mobilize a fused joint (BAD IDEA!) OR try to restore motion that cannot be restored** * **​Contact Surgeon** **​**
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Bunionectomy ## Footnote **Progressive ex. program**
* Progressive Ex. program **initiated EARLY post-OP can help REDUCE comps assoc'd w/ long term immob.**
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Bunionectomy ## Footnote **Maintenance of ROM:**
* maint. of ROM **in early phases of rehab ----\>** shown to be beneficial in a study assessing the role of **cont. passive motion**
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Bunionectomy ## Footnote **Typ clinical scenario** **EBP===\>**
* pt 12wks after sx referred bc **excess stiffness, pain, trouble walking** * **​surgeons often say "just go walk"** * **EBP== _early_ motion, _early_** **progressive ex. program\*\*\*\*\***
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MSPT I
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