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MSK Practical Exam > Ankle Pathologies > Flashcards

Ankle Pathologies Flashcards

1
Q

What are the 3 lateral ankle ligament called?

A

Anterior talo-fibula ligament

Calcaneofibula ligament

Posterior talo-fibula ligament

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2
Q

What are the grades for a lateral ankle sprain?

A

Grade I, II, III

Grade II and III instability is present

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3
Q

What are the 4 deltoid ligaments called?

A
  1. Anterior tibiotalar ligament
  2. Posterior tibiotalar ligament
  3. Tibiocalcaneal ligament
  4. Tibionavicular ligament
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4
Q

What injuries are usually associated with deltoid ligament injuries?

A

Lateral ankle sprains

Fractures

Syndemosis injuires

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5
Q

What movement does the deltoid ligaments prevent?

A

Eversion

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6
Q

What are the clinical features to diagnose a deltoid ligament sprain?

A

Popping sensation

Pain & Swelling

Exclude tibialis posterior injury

MRI

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7
Q

Name the 2 peroneal muscles and there origin and insertion?

A

Peroneal brevis and longus

Origin - Shaft of fibula

Insertion - Base of 5th metatarsal

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8
Q

What is the function of the peroneal muscles?

A

Wrap around lateral malleolus like a pully

Eccentrically control inversion and everts ankle

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9
Q

What associated injuries are common with lateral ankle sprains?

A

Base of 5th metatarsal fractures and peroneal tendon dislocations

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10
Q

What is a common overuse injury for the peroneal muscles?

A

Tendinopathy

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11
Q

What is the clinical presentation of a peroneal injury?

A

Pain localised posterior to lateral malleolus and tracks to lateral hind foot = peroneal trochlea on calcaneus and cuboid tunnel under foot

Pain on resisted PF and eversion

Snapping tendon across lateral malleolus

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12
Q

What are the Ottawa Ankle Rules and what are the 4 areas to palpate?

A

Assessment for potential ankle fracture

  1. Distal posterior 6cm of the fibula
  2. Distal posterior 6cm of the tibia
  3. Base of the 5th metatarsal
  4. Navicular tubicle
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13
Q

Using the Ottawa Ankle Rules, when is an x-ray required?

A

Bone tenderness on 1 of the 4 bony areas plus the inability to take 4 complete steps

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14
Q

What factors may affect your clinical judgement for an x-ray using the Ottawa Ankle Rules?

A

If the patient has other distracting painful injuries

Diminished sensation in the legs

Swelling which prevents palpation

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15
Q

What are the different types of 5th metatarsal fractures associated with inversion sprains?

A

Starting from proximal to distal:

Tuberosity avulsion fracture

Jones fracture

Stress fracture

Shaft fracture

Head fracture

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16
Q

What 5th metatarsal fractures are most common with a peroneal brevis injury?

A

Tuberosity avulsion fracture

Jones fracture

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17
Q

What is the Weber Ankle Fracture Classification?

A

Regarding lateral malleolus fibula fractures

Type A - fracture distal to syndesmosis. Usually stable. Associated with inversion injuries.

Type B - Most common. Fracture at level of syndesmosis with variable stability. Associated with inversion injuries.

Type C - fracture proximal to syndesmosis and often associated with syndesmosis injury. DF and eversion mechanism.

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18
Q

If the medial malleolus is fractured as well as the lateral malleolus what treatment is required?

A

Open reduction and internal fixation (ORIF)

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19
Q

What are the different ways a syndemosis injury can occur?

A

Injury to:

Anterior inferior tibiofibula ligament

Posterior inferior tibiofibula ligament

Interosseous ligament

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20
Q

What is the treatment if any of the ligaments involved with syndesmosis injuries have ruptured?

A

Surgery

Injury to interosseous = cast and surgery

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21
Q

What sign indicates the need for syndesmosis testing?

A

Pooling of blood lateral and anterior foot

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22
Q

What are the signs and symptoms of syndesmosis injuries?

A

! Inability to hop

! DF and ER pain

! DF and ER foot planted mechanism

! Inability to walk

! Pain out of proportion

! Pain in shin or knee during mechanism

! Feeling of instability

More pain compared to an ATFL injury

Unable to weight-bare, especially downstairs

Localised tenderness around anterior inferior tibiofibular ligament

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23
Q

Where should you palpate for syndesmosis injuries?

A

Whole leg due to high force mechanism

Anterio-lateral over tibia

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24
Q

What are the 4 compartments of the lower leg?

A
  1. Anterior compartment
  2. Lateral compartment
  3. Deep posterior compartment
  4. Superior posterior compartment
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25
Q

Which 2 compartments does compartment syndrome most likely occur?

A
  1. Anterior (40-60%)

2. Deep posterior (30-60%)

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26
Q

What is compartment syndrome?

A

Swelling that occurs within one of the compartment and affects the nerves, veins, muscles and arteries

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27
Q

What are the compartments divided by and why is this important?

A

Fascia which is not flexible

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28
Q

What is the effect of compartment syndrome on the nerves, veins, arteries and muscles?

A

Muscles - weakness

Obstruct nerves, veins and arteries that lead to altered sensation and loss of blood flow (feleing of deadness)

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29
Q

What are the 2 pulses in the foot and ankle? And when would you tests for these?

A

Posterior tibial pulse

Dosal pedis

Compartment syndrome

30
Q

What structures are within the anterior compartment?

A 
Muscles
Tib Ant
Extensor digitorum longus
Extensor hallucis longus
Peroneus tertius

Vessles
Anterior tibial artery and vein

Nerve
Deep peroneal nerve

31
Q

What structures are within the lateral compartment?

A

Muscles
Peroneus longus and brevis

Nerve
Superficial peroneal nerve

32
Q

What structures are within the deep posterior compartment?

A 
Muscles
Flexor hallucis longus
Flexor digitorum longus
Tib post
Popliteus

Vessles
Posterior tibial artery and vein
Peroneal artery and vein

Nerve
Tibial nerve

33
Q

What structures are within the superficial posterior compartment?

A

Muscles
Soleus
Gastroc
Plantaris

Vessels
Branch of tibial artery and vein

Nerve
Sural nerve

34
Q

What area of the foot will a patient get numbness, pins and needles or deadness due to anterior compartment syndrome?

A

Between big toe and 1st phalanx

35
Q

What area of the foot will a patient get numbness, pins and needles or deadness due to deep posterior compartment syndrome?

A

Heel and plantar fascia

36
Q

What population is at greater risk medial tibial stress syndrome?

A

Runners, heavy boot workers (army) and agriculture

37
Q

What factors increase the risk of someone getting medial tibial stress syndrome?

A

! Increase in training volume

! Altered running mechanics -contralateral pelvic drop and increased ankle eversion

Increased High BMI

Increased Navicular drop

Greater ankle PF ROM

Greater hip ER

38
Q

What are the subjective indicators of medial tibial stress syndrome?

A

Recent change in training load

Exercise aggravates symptoms and rest eases symptoms

39
Q

How do you diagnose medial tibial stress syndrome?

A

Tender on palpation of the distal 1/3 of the medial tibia (of at least 5cm)

40
Q

What is tarsal tunnel syndrome?

A

Tibial nerve gets compressed posteriorly and inferiorly behind medial malleolus

41
Q

What are the structures of the medial ankle?

A

Medial malleolus

Tom - Tib Post

Dick - Flexor digitorum longus

And - Posterior tibial artery

Very - Posterior tibial vein

Nervous - Tibial nerve

Harry - Flexor hallucis longus

Tom is anterior and Harry is posterior

42
Q

Where does tib post insert?

A

Navicular tuberosity

43
Q

What type of pain does tarsal tunnel syndrome cause?

A

Neuropathic pain

44
Q

What would you find/do in an objective assessment for tarsal tunnel syndrome?

A

Tinels sign

Muscle weakness

Numbness distribution - follows the tibial nerve usually through medial arch of the foot

Neurodynamic testing

Palpation of the nerve

45
Q

What is the subjective indicators of plantarfascitis?

A

Plantar medial heel pain: most noticeable with inital steps after a period of inactivity but also worse following prolonged weight bearing

1st thing in the morning is very painful

Heel pain followed by a recent increase in weight bearing activity or change in footwear

Common in people with jobs that have a lot of walking e.g. army and postmen

People with poor foot biomechanics

46
Q

How do you diagnose plantarfacitis?

A

Pain on palpation of the proximal insertion of the plantar fascia (medial point of calcaneus)

Positive Windlass test

47
Q

How do you differentiate between plantarfascitis and tarsal tunnel syndrome?

A 
Plantarfascitis
No numbness or paraesthesia
Worst thing in the morning
No night pain
Usually a change in load
Will get pain initially when walking after rest before pain decreases

Tarsal Tunnel
Pain medial aspect of heel and arch
Paraesthesia and numbness on plantar aspect of foot (but not always)
Idiopathic (no change or cause) 80%
Can report pain eases with walking after period of rest (no pain initially)
Night pain

48
Q

How does tibialis posterior tendinopathy or dysfunction present?

A

Medial ankle pain and can extend to medial foot

Biomechanical/postural changes in the foot

Most common biomechanical change = pronation (foot arch drop)

49
Q

What is the management of tibialis posterior tendinopathy or dysfunction?

A

Correct foot posture

Strengthen tib post and lower leg

50
Q

What tests would you do for tibialis posterior tendinopathy or dysfunction?

A

Navicular drop test

Foot posture index

51
Q

What are the red flags specific to the lower limb?

A

Fracture

Compartment syndrome

Septic arthritis

Cellulitis

Deep vein thrombosis (DVT)

Peripheral arterial occlusion disease (PAD)

52
Q

What is important to consider regarding the association between foot biomechanics and pain?

A

Pain may cause poor biomechanics

Poor biomechanics may cause pain

Or no association

53
Q

What is the most common mechanism of achilles ruptures?

A

Participation in power sports

When someone goes to push off after being sedentary

40-45 years as people are sedentary over winter then start physical activity again

54
Q

What style of training should you prescribe for prevention and return to sport for achilles ruptures?

A

Plyometrics

55
Q

What is the patient history for achilles ruptures?

A

Feels like a kick in the back of the leg and audible bang

56
Q

How do you diagnose achilles ruptures?

A

Level of gap in the tendon

Thompson test

57
Q

What is the mechanism of a gastroc tear?

A

Active PF with knee extension

MTJ most vulnerable

Common in sports

58
Q

What is the clinical presentation of a gastroc tear?

A

40-60 years

Sudden pain and pain on weight bearing

Feel like being hit by a stick in the back of the leg

Substantial swelling and potential extensive haematoma due to being a high vascular muscle

59
Q

How does a gastroc tear present on assessment?

A

Pain and swelling around medial head

Pain on active or passive DF

Decreased PF power

Palpable defect in medial belly of gastroc

Thompson test is negative

Often confused with DVT or Bakers cyst

60
Q

What is the mechanism of a Lisfranc fracture?

A

Hyper PF

61
Q

What is a Lisfranc fracture?

A

Fracture and/or dislocation of the metatarsal

Most common is the 2nd metatarsal

Can happen to the 3rd and 4th metatarsal

The fractured metatarsal dislocates dorsally

62
Q

What is the clinical presentation of a Lisfranc fracture?

A

Midfoot tenderness

Midfoot swelling

Midfoot instability and rotation pain

! Forced the head of the metatarsal into abduction and DF and this reproduces symptoms

63
Q

What is the clinical assessment of a navicular stress fracture?

A

Overuse and repetitive trauma (foot sprains)

Pain on explosive start/push off

Tenderness on palpation of the navicular tuberosity

X-ray not very useful

64
Q

What is Morton’s neuroma and the clinical presentation?

A

Tissue around the nerve thickens from irritation/compression

Usually occurs in 3rd webspace between tarsals

Pain, burning, paraesthesia underneath toes

Related to change in running load

More exercise the patient does, the worse the pain gets

65
Q

How do you diagnose Morton’s neuroma?

A

Usually occurs in 3rd webspace between tarsals

Squeeze test - Grab heads of metatarsals 1-5 and squeeze
Positive if it reproduces pain

Ultrasound to confirm

66
Q

What is the management of Morton’s neuroma?

A

Steroid injection

67
Q

Name the 2 joint lines of the foot?

A

Lisfranc joint line (cuneiform and metatarsals)

Chopart joint line (Calcaneus with cuboid / talus with navicular)

68
Q

Name the 4 ankle joints

A

Talocrural joint (distal tib and fib with the talus)

Subtalar joint (Talus and calcaneus)

Distal tib fib joint

Midtarsal joint (Calcaneus with cuboid / talus with navicular)

69
Q

What are the general red flags?

A

Hx of cancer

Constant progressive unremitting night pain

Unexplained weightloss

Radiotherapy / Chemotherapy

IV drug abuse

Alcohol and drug abuse

Long-term steroid abuse

Osteoporosis

Rheumatoid arthritis

Anticoagulants

Asthma

Epilepsy

Diabetes

Cardiac and circulatory problems

Hx of trauma

Cauda equina

Pregnancy

Poor general health

5Ds & 3Ns - Diplopia, dysarthria, dysphagia, nystagmus, nausea, numbness

70
Q

What are the special tests for the lateral ankle ligaments and the deltoid ligament?

A

Talar tilt

Anterior drawer

MSK Practical Exam (11 decks)

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