Ankle Flashcards
(20 cards)
SHIN SPLINTS / RUNNER’S LEG
By origin of the clinical S&S
1. Muscular - tibialis posterior and anterior syndromes, soleus syndrome
2. Periosteal - periostitis of tibia
3. Fascial - exertional compartment syndrome
4. Osseous - tibial and fibular stress fractures
- Tibialis posterior syndrome
- Tibial periostitis/ medial tibial stress syndrome (mtss)
- Exertional compartment syndrome (ecs)
- Stress Fractures of Tibia
- Tibialis posterior syndrome
Caused by biomechanical dysfunction (esp.hyperpronation) of the foot and ankle?
-Pain usually appears at the beginning of a workout and later disappears, only to reappear afterwards.
-Palpable tenderness along the medial side of the lower leg
-Tenderness is also elicited by resisting plantar flexion and inversion of the foot.
-Radiography helps to r/o stress fracture of tibia/ tibial periostitis.
- Tibial periostitis/ medial tibial stress syndrome (mtss)
Less frequent than tibialis posterior syndrome
Periosteal changes - periostitis (inflammation of the periosteum) along the posteromedial tibial border, usually the distal 1/3
periostitis of the soleus insertion along the posterior medial tibial border, as a result of excessive pulling of
the muscle. Excessive pronation or prolonged pronation of the foot causes an eccentric contraction of the soleus, resulting in periostitis
Other contributing factors include:
Changing in running distances, speed, form, stretching, footwear, or running surfaces.
On examination
Tenderness along the anterior side of the tibia and sometimes slight swelling and thickening above the bone can be noticed
Bone scans help to differentiate from a stress fracture
Additional treatment - ice and NSAID, soft running surface, cushioning of the hee
- Exertional compartment syndrome (ecs)
Anterior compartment -
Activity leads to increased muscle volume (hypertrophy) resulting in an increase in the intra- compartmental pressure.
As the pressure rises, the venous return is diminished, thus producing a further rise in pressure.
The raised pressure can result in nerve compression and therefore neurological symptoms (i.e. foot drop- deep peroneal nerve)
In severe cases the arterial supply can be cut off by compression.
ECS is characterised by exercise induced pain and swelling that is relived by rest.
Patient cannot train through the pain
The compartments most frequently affected are the anterior (50 to 60%) and deep posterior 20-30%
Chronic ECS is usually seen in well-conditioned athletes younger than 40.
Signs and Symptoms
Exercise induced aching leg pain and a sense of fullness, both over the involved compartment. These symptoms are almost always relived by rest, usually within 20 minutes, only to recur if exercise is resumed.
Bilateral is common
Activity related pain begins at a predictable time after starting exercise or after reaching a certain level of intensity
Many individuals with anterior ECS describe mild foot drop or paraesthesia (or both) which are amplified by physical exertion due to deep peroneal nerve compression.
Additional Treatment
Ice and reducing the level of strain, for an active individual
fasciotomy provides a quicker and long-term solution
Acute Compartment Syndrome
A rapid increase in tissue pressure, it tends to occur as a result of a direct blow to the anterolateral aspect of the tibia, or by a tibial fracture. The anterior compartment is particularly at risk.
Signs and Symptoms
Recent history of trauma, excessive exercises, prolonged external pressure
The increasing severe pain and swelling appear to be out of proportion
A firm mass, tight skin, loss of sensation on the dorsal aspect of the foot
Possible diminished dorsalis pedis pulse
Treatment
Medical emergency
- Stress Fractures of Tibia
As a result of repeated submaximal loading. Dull pain, swelling and palpable tenderness is confined within 2-3 cm in diameter.
Signs and Symptoms
Insidious onset
Increase with activity/ decrease with rest
Pain usually limited to fracture site
Pain on percussion and vibration (possibly)
Ottawa ankle rules
- Posterior edge or tip of medial lateral malleolous
- Posterior edge or tip of medial malleolous
- Base of 5th metatarsal
- Navicular
-Ankle x ray series is required only if there is any pain in malleolar zone with pain at 1 & 2
-Inability to bear weight immediately or in emergency
-Foot x ray series is required only if there is any pain in midfoot zone 3 & 4
- Inability to bear weight immediately or in emergency
Ankle Sprains
-Ankle sprains are common and have been estimated to occur in 1 per 10,000 of the population per day and account for 10-28% of all sporting injuries
-There is also a high risk of developing chronic ankle instability (CAI) resulting in recurrent ankle sprains which have been reported to be in excess of 70% to 80% in some sports.
- It is estimated that the majority (55%) of people who suffer ankle sprains however do not seek medical care
Lateral Ankle Sprain (Inversion sprain)
-Anterior talofibular ligament (ATFL) sprain is the most common of lateral ligamentous injuries of the ankle involve in 97% of injuries either by itself of with others
- Forced inversion when the foot is plantar flexed
-20% combined AFTL plus Calcaneofibular ligament (CFL)
-3% isolated rupture of CFL
Signs and Symptoms
-Pain on walking/loading
-Swelling/tenderness, blood effusion >bruising
-Instability – tested by anterior drawer tests and inversion stretching
-May detect ligamentous deficit (sulcus) between fibular and talus on inversion
- May associate with avulsion fraction of lateral malleolus – compression and distraction tests (Ottawa Ankle rules)
- Occasionally associated with a calcaneofibular ligament sprain
High Ankle Spain
*Distal tibiofibular joint is a syndesmosis allowing limited superior and inferior gliding
and rotation between thetibia and fibula
*The joint is stabilized by a thick interosseous membrane
together with the anterior and posterior tibiofibular ligaments.
*Injury of the distal tibiofibular syndesmosis (high ankle sprain)
has been estimated to occur in 1–11% of all ankle sprains, This can result in instability of the talocrural joint
Mechanism of injury-
-The most common mechanism of injury being forced external rotation or hyperdorsiflexion of the foot.
-The Syndesmosis however can be injured on eversion and inversion sprains, though the forces needed usually result in an accompanying fracture of the fibula.
Medial Ankle Sprain
Forced eversion
Involved in less than 10% of ankle injuries
Deltoid ligament sprain, may increase pronation of foot
Chronic ankle instability (CAI)
The development of CAI has been attributed to mechanical and functional instability or a combination of both.
Mechanical instability is described as an abnormal movement of the ankle complex related to pathological ligamentous laxity, impaired arthrokinematics, or degenerative joint disease.
Functional instability is the tendency for the ankle to “give way‟ during normal activity without abnormal joint movement being present and has been related to impairment in ankle proprioception, neuromuscular activity, postural control or muscle strength.
Plantar Fascitis
Planter fasciitis commonly causes inferior heel pain and is believed to be the result of either acute or chronic accumulative overload stress to the origin of the planter fascia. It occurs in up to 10% of the North American population
This condition can affect active and sedentary adults of all ages, however is associated with obesity, prolonged standing and limited ankle flexion
The pain associated with planter fasciitis may be described as throbbing, searing, or piercing, especially on initial weight bearing in the morning or after inactivity. The pain usually improves on further ambulation though may worsen on continued weight bearing often limiting activities of daily living (ADL) Walking up stairs, barefoot or on toes may also exacerbate pain.
Palpation usually reveals tenderness around the medial calcaneal tuberosity at the planter aponeurosis
-Diffuse discomfort to pressure over rest of heel and into medical arch
- Painful muscular and ligamentous attachments
- Pain reproduced by dorsiflexion of toes and ankle
-Worst in the morning, then eases, re-occurs with activity
Etiology:
- Usually related to hyperpronated foot? with weakened intrinsic muscles and ligaments
- Triggered by prolonged standing/walking, poor footwear
Management
- Control inflammation and pain
-Manipulation and soft tissue treatment of foot
- Correct/ normalise biomechanics ?
- Lifestyle advice
DDX: Sever’s Disease (Calcaneal apophysitis)
- Heel pain in athletically active child due to increase calf muscles activity
8-15 yo
Pain particulary during rapid growth period where the achillies tendon attaches
Achilles Tendinitis/ tendinopathy
-Acute achilles tendinitis is the painful inflammation of the paratendon with or without swelling around the tendon that may be self limiting or can be prone to chronicity
-Achilles tendinopathy encompasses a range of histological labels (paratendonitis, tendinitis, tendinosis) and represents a spectrum of overuse conditions that affect the tendon, either at its insertion or mid portion.
-Tendinosis is characterised by non-inflammatory intra-tendinous collagen degeneration resulting in fibre disorientation, reduction of tenocytes, increased inter-fibrilar glycosaminoglycan’s, increased type III collagen and neovascularisation.
Aetiology:
-Mechanical loading (magnitude, frequency, duration and rate of loading)
- Excessive shear
- Compressive forces.
Intrinsic risk factors:
- Advancing age,
- Obesity
- Genetics (COL5A1 and TNC genes)
- Gender (F>M)
Clinical Presentation
- Pain on getting out of bed in the morning - gradually eases
- Burning pain over tendon at the beginning of activity, becoming more nsevere and worsening
- Tenderness over posterior insertion on calcaneus
Chronic cases
Pain after exercise, which may become constant
May develop crepitus, swelling, tender nodules, and tendon thickening.
Pathologically, the tendon demonstrates chronic degeneration rather than inflammation.
Management
-Rest, ice, stretching, modalities (acute phase)
-Treat abnormal mechanics of lower limb, modify training
- Most evidence suggest progressive eccentric strengthening exercises (3-4 months) without and then with load.
- Change shoes or provide external support
- Cortisone injection is generally contra-indicate
Hallux Rigidus
Hallux rigidus is a fairly benign condition
-Hallux rigidus (hallux limitus) > DJD of the first MTPJ with stiffness and deformity. MC 2nd to1st MTP joint (hallux valgus is first).
- Females X2
- Wide age range at presentation, from adolescence to the 9th decade. Mean age 43 years. Adolescent disease appears to show the same degenerative process and it is not thought to be due to separate pathology.
- 80% are unilateral at presentation. However, at 9-year follow-up 80% have bilateral involvement (Coughlin and Shumas 2003)
-Pt presenting with unilateral hallux rigidus will usually have an asymptomatic osteophyte and/or reduced dorsiflexion of the opposite hallux
- A history of trauma is commoner in females, and 78% of unilateral HR is associated with trauma, however not all studies report a significant correlation
- There is no association with shoewear or occupation
Gouty Arthritis
General Descriptions (Adams)
- Usually starts with the big toe and recurrent attack in elbow
- Associated with olecranon bursitis
Clinical Presentation
- Acute – pain, inflammation, swollen, red and glossy
- Chronic – multiple joints involved with deformity, palpable tophi nodules
- Radiographic findings – chronic erosion and periarticular degeneration
- Lab findings – increased ESR and serum uric acid level, crystal deposition
Morton’s neuroma
- Common source of forefoot pain
- Sometimes bilateral
- Trauma or repetitive stress caused by tight fitting shoes or pronated foot putting abnormal pressure on the planter digital nerves as they are compressed between the metatarsal heads and transverse intermetatarsal ligament
- Most common 2 /3 or ¾ intermetatarsal spaces
Signs and Symptoms:
- Sensation of having a stone in the shoe that worsens with standing
- Tingling or burning radiating to the toes along with intermittent sharp pain.
- Painful mass and pain on palpation between the metatarsal heads
Tarsal Tunnel Syndrome
- Occurs when the posterior tibial nerve or one of its branches becomes constricted beneath the fibrous roof of the flexor retinaculum in the foot.
- The lateral planter nerve branch tends to be the most frequently affected branch.
- This condition is often linked with excessive pronation or excessive valgus deformity that leads to stress or traction.
Signs and Symptoms:
- Patient complains of pain at the medial malleolus radiating into the sole of and heel. Together with, paresthesia, dysesthesia and hyperthesia.
- Positive tinels sign over the course of the nerve.
Lisfranc
- Injury is referred to as a Lisfranc if there is any disruption of the tarsometatarsal joint complex
- Transverse ligaments connect the bases of the four lateral metatarsal#
