Ankle Flashcards
(25 cards)
Joints of the ankle
talocrural
inferior tibiofibular
Subtalar
Talocrural JT
• Articulation between the talus, medial malleolus (distal tibia) and lateral malleolus (distal fibula)
– 1° Weight-bearing synovial joint • Designed for stability
– Uniaxial modified hinge joint
• Flexion (plantarflexion)/extension
(dorsiflexion)
• Combined movements of inversion/eversion possible with subtalar joint
Inferior tibiofibular joint
• Articulation between the distal tibia and the distal fibula – Syndesmosis • Designed for stability – Slight “give” during dorsiflexion • High ankle sprains
the subtalar joint
• Articulation between the talus and the calcaneus
– Plane synovial joint
• Pronation accompanied by calcaneal eversion (calcaneovalgus)
• Supination accompanied by calcaneal inversion (calcaneovarus)
lateral ligaments
ATFL
CFL
PTFL
Medial ligs
deltoid ligament
PE
• Observation
– Consider relevance of alignment inc. medial/ lateral/ transverse arches of the foot
• Baseline functional test – can you replicate the primary complaint?
– E.g.Walking,running,hopping,SKB
• Active Movement
– Rangeofmovement(ROM);quantity,andquality(andwhatlimits,e.g. pain, caution etc)
• Passive Movement
– Rangeofmovement(ROM);quantity,andquality(andwhatlimits
(End feel), e.g. pain, caution etc)
• Resisted tests
– Isometric,Isotonic,Functional;painandweakness
•
Palpation/Special tests/neurological assessment
– Specifictopathology/clinicalreasoning,and/orclearingtests?
• ‘Special’ orthopaedic tests
– Anteriordrawertest
– Talartilt
– Klieger’stest/externalrotationtest – Squeezetest(Thompson’stest)
– Compressiontest
• Any indication for vascular testing, e.g. skin colour changes, temperature changes
• Femoral pulse
• Popliteal pulse
• Posterior tibial pulse • Dorsalis pedis pulse
OTTAWA Ankle Rules
bony tenderness on medial/lateral malleolus 6cm up
Navicular
base of the 5th metatarsal
inability to weight bear both immediately and in the ED
Lateral ankle sprain
•Most common ankle injury (Nuhmani and Khan, J Musculoskelet Res 2013, 16(4)).
• One study showed that 70% of their
basketball players had a history ankle
sprain and 80% of them had multiple
sprains (Smith and Reischl, Am J Sports Med 1986 14 p 465)
– Jumping sports
– Running/cutting sports
lateral ankle sprain clinical presentation
• MOI: Excessive supination/inversion (± plantarflexion) – ATFL is the first to rupture (Nuhmani and Khan, J Musculoskelet Res 2013, 16(4)) • Signs and symptoms – pain+ – swelling/±Ecchymosis – instability – WB or NWB? • Differential Diagnosis – Syndesmosis sprain – Fractures
Lateral ankle sprain - diagnosis
• Patient History – MOI
• Palpation
• Ottawa ankle rules – X-ray • Special tests
• Outcome Measures
– Lower Extremity Functional Scale (LEFS) – Foot and Ankle Disability Index
– LLTQ
Lateral ankle sprain - mgmt
• Acute Phase (24 – 72 hours) – POLICE –
•OL Depend on grade of injury – Ankle pumps 10 – 20/hour
– Active and passive soft tissue techniques
– Transverse friction to improve healing – caution on the grad of injury.
(Walker J Orthop Sports Phys Ther 1984 6(2) p 89)
– Crutches (gait retraining) - WBAT
– Ottawa Ankle Rules (Imaging)
– Depending on severity (hydrotherapy)
– Taping/bracing
(Nuhmani and Khan, J Musculoskelet Res 2013, 16(4))
Lateral ankle sprain mgmt reparative phase
– Joint mobilizations
– Passive stretch (gastroc/soleus)
– Isometric exercise (as soon as the patient can tolerate) – Strengthening (peroneii, TA, extensors, triceps surae) – Proprioception (standing and sitting)
– Shoe assessment – Taping/bracing
lateral ankle sprain - mgmt remodelling phase
• Remodeling Phase (15 – 28 days, 3 weeks 60% strength, 3 months 100% strength)
– Begin running/jumping forward and backwards – Incorporation of multidirectional agility drills
– Progress to jumping sideways (over a line)
– Progress to box drills
– Incorporate multidirectional sports-specific proprioceptive exercises
– Simulated sport-specific exercises
Chronic ankle instability prevalence
• Estimated that 30% of people will develop CAI after initial sprain (Itay et al.
Orthopaedic Review 11(5), p73) • Mechanical (MAI)
– laxity of a joint due to loss of mechanical restraint (ligamentous)
• Functional (FAI).
– perception/realisation that the ankle gives
way, is weaker, more painful
CAI - clinical presentation
• Recurrent ankle sprains • Giving way • Altered activity level Outcome Measures: – Cumberland Ankle Instability Tool – Ankle Instability Instrument – Identification of Functional Ankle Instability Questionnaire – Foot and Ankle Disability Index – FootPostureIndex(FPI)
CAI clinical Dx
• Patient history (recurrent ankle sprain)
•Special tests (ligament laxity/rupture)
• Altered neuromuscular control – impaired balance (SEBT, TTS)
– Impaired proprioception
– Impaired strength
– Slower firing of peroneal muscles (?) – Single Leg Stance
– Proprioception testing/balance
• SEBT, TTS
• Imaging (x-ray, MRI)
CAI mgmt
• Physical Therapy • Strength • Neuromuscular control – EMG biofeedback – US – as feedback (diagnostic) • Proprioception/balance • Ankle supports/braces • Foot orthoses (poor evidence) – Increasing strength – Improving joint position sense – Improving functional test • Single leg hoping • Single and triple hop for distance • 6m and 6m crossed hop for time
Causes of posterior ankle pain
achilles tendinopathy achilles rupture retrocalcaneal bursitis posterior impingement syndrome Sever's disease Achilles bursitis referred pain inflammatory entheseopathies
AT - prevalence
• Incidence of 1.9 / 1,000 registered patients (GP clinic)
– Associated with physical activity (Maffulli et al., JRSM 97(10) p472)
– 58 cases 1⁄3 of patients did not participate in sport (Rolf and Movin
Foot Ankle Int. 1997 18(9) p565)
AT clinical presentation / Dx
• Signs and Symptoms – Typically 2° Overuse &/or change in activity level/type – Pain – Activity related pain – Tendon thickening – Pain on palpation – Reduced strength (Pain) – Stiffness of the tendon – Imaging – Ultrasound – Outcome Measure: VISA-A
AT - mgmt/evidence
• Systematic Review on different protocols – Alfredson Exercise Protocol (Eccentric exercises)
• 3 sets x 15 reps twice daily, both w knee bent and straight
• heterogeneity of other studies limits other exercise protocols
– modified activity
– advice and education
– corticosteroid injection
• Evidence for short term relief (4/52) but with long-term
complications (6&12/12) (Coombes et al., 2010 Lancet 376(9754) p1751)
• 63% recurrence (Bisset et al., BMJ 2006, 33 p939)
Therapeutic tendon loading exercises
• Exercise prescribed to ‘load’ the tendon
– Gravity alone or in tandem with weights, e.g. hand-weight, body-weight or resistive exercise band etc
• Popularised by Alfredson et al in the ‘90’s in relation to Achilles tendinopathy
– 15 recreational athletes with Achilles pain who had failed previous conservative care. Responded to a programme of heavy-load eccentric calf muscle training (Alfredson et al, 1998. Am J Sports Med 26: 360)
• Initially thought to stimulate remodelling of the tendon
• Now one of the most common conservative interventions for tendinopathy related pain
• Applied across the range of tendinopathies:
– Rotator cuff tendinopathy (e.g. Littlewood et al 2012, 2013)
– Elbow extensor tendinopathy (e.g. Croisier et al 2007)
– Patellar tendinopathy (e.g. Young et al 2005 )
– Achilles tendinopathy (e.g. Norregaard et al 2007 )
• But:
– TTLE is not a ‘one-size fits all approach’
• Some patients seem to benefit and others do not
– The patho-aetiology of tendinopathy remains poorly understood
– The mechanism of action of TTLE remains poorly understood
• See Drew et al., BJSM 2014, 48(12) p966; Allison and Purdam, BJSM 2009 43(4) p276 for more information
talus
• Irregular shape – Movement controlled by bony ar/cula/ons • Posterior ar/cula/on with sustentaculum tali of calcaneus • Body, head and neck – Head and neck palpable – Head – navicular ar/cula/on – Neck • Medially /b ant & /b post • Laterally – sinus tarsi • Sinus tarsi – Neck and ATFL palpable – TOP indicates??
