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Ankle conditions Flashcards

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1
Q

What is the epidemiology of lateral ligament sprain

A

5000 injuries in the UK daily
Suffered by over 50% of the population
25% greater risk of grade 1 sprain in female athletes than male
One of the most common mSK injuries
11% of any injury are ankle sprains
Most common sports injury

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2
Q

What is the aetiology of lateral ankle sprain

A

forced plantar flexion with inversion
Jumping / landing
Uneven surfaces when walking or running
foot to foot contact
greater risk if have postural sway

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3
Q

What are the commonly injured structures
in lateral ankle sprain

A

lateral ligament complex
ATFL is damaged in 65% of inversion sprains
Combined injury of ATDL and CFL in 20% of injuries
PTFL very rarely injured as very strong

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4
Q

Pathophysiology of lateral ligament injury

A

Bleeding and inflammation occurs
Proliferation occurs
ie growth of new capillaries and proliferation of fibroblasts producing collagen
remodelling phase begins

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5
Q

Diagnosis of Anterior tibiofemoral ligament

A

Active ROM, anterior draw test, palpation

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6
Q

Diagnosis of calcaneofibular ligament

A

medial talar tilt, palpation

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7
Q

diagnosis of posterior talofibular ligament

A

palpation

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8
Q

What are possible parts conditions for differential diagnosis with lateral sprain

A

Syndysmosis injury (squeeze test, external rotation test, shuck test)
Fracture (malleolar, base of 5th metatarsal, navicular)
Tendons (peroneal tendon leads to dislocation)
Osteochondral lesion of talar dome

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9
Q

When should tests occur for lateral ankle sprain?

A

Manual tests best 4-7 days after pain and spasm reduced
Should be kept simple initially
Area of maximal swelling and tenderness usually indicates injured structures

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10
Q

what kind of imaging should be done for lateral ankle sprain

A

X-ray to rule out fracture
MRI of talar dome

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11
Q

What are the aims at the acute stage for lateral ankle sprain

A

Reduce pain, reduce swelling, prevent further tissue damage

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12
Q

What treatment should be used in early stages of a lateral ankle sprain

A

PRICE (protection, rest, ice, compression, elevation)

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13
Q

What are the benefits of ice

A
  • ↓Pain via ↓nerve conduction velocity.
    – ↓Tissue metabolism.
    – ↓Rate secondary cell destruction.
    – ↓ oedema formation
    – Vasoconstriction → ↓ oedema formation
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14
Q

what should be used during compression in lateral ankle sprain and why?

A

Compression pad and elastic bandage
Elastic bandages help to stop compartment syndrome
Felt pad is around ankle and helps to ensure swelling doesn’t remain around ankle

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15
Q

What kinds of medical management in initial stage are there for lateral ankle sprains and what are the benefits

A

NSAIDS (less pain, return to training faster, increase exs endurance on return to training)

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16
Q

what is the treatment and aims of intermediate stage of a lateral ankle sprain

A

Continue to decrease pain, swelling and risk of damage
Promote:
Healing and tensile strength + mobility of tissue
Restore normal ROM, flexibility, muscle strength and neuromuscular function to include balance and gait

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17
Q

What are possible exercises and focusses in the last stages of a lateral ankle sprain

A

jogging
agility drills
sprints
directional-change
plyometrics
Functional / sports-specific

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18
Q

what can reduce the incidence of sprains in sport in general

A

Taping

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19
Q

What is a osteochondral lesion of talar dome?

A

shallow, wafer-shaped lesion of articular cartilage and subchondral bone

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20
Q

what are the symptoms of osteochondral lesion of talar dome

A

Excessively severe or prolonged joint pain
Tenderness on anterior joint line palapation
May not appear on initial x-rays and MRI should be considered

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21
Q

What is the epidemiology of lateral ankle sprain

A

Common in athletes such as american footballers and downhill skiers
account for 1-11% of all injuries
Incidence of 29% in american footballers

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22
Q

What is the aetiology of syndesmosis injuries

A

Most commonly caused by extreme external rotation or dorsiflexion of the talus

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23
Q

what is the key anatomy involved in a syndesmosis injury

A

ligaments that bind distal tibia and fibula

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24
Q

what other injuries often occur with syndesmosis injuries?

A

Fractures of the malleolus or proximal fibular spiral fractures

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25
What are key clinical features of syndesmosis injuries
Less swelling than lateral ankle sprains loss of full flexion and inability to weight bear Ecchymosis may appear several days post-injury due to injury to the interosseous membrane Difficulty walking
26
what are possible differential diagnosis components for syndesmosis injuries
Tibia, fibula and talus fractures should be ruled out Lat ankle sprain medial ankle sprain compartment syndrome severe joint laxity severe contusion dystrophic calcification infection tumour
27
What are the key components of examination for syndesmosis injuries
Observation Palpation (key areas are proximal to anterior tibiofibular ligament and proximal interosseus membrane, medial and lateral malleoli, fibula from distal to proximal tibiofibular joint to rule out maissoneuves #) Distal pulses Girth measurements
28
What special tests may be used for syndesmosis injury?
Kleigers tests Squeeze test Cotton test / shuck test Fibular translation test
29
How is the external rotation stress test (or kleigers test) carried out and what does it test?
it determines if theres damage to the deltoid / medial collaterol ligament or tibiofibular syndesmosis Knee is in 90 degree flexion and ankle is in neutral with hand underneath bring foot into maximal dorsiflexion and then into external rotational force is applied to foot and ankle + if patients anterolateral pain is reproduced
30
what does the squeeze test show and how is it conducted
allows separation of tibia and fibula, also indentifies fibular fracture or syndesmosis sprain pt in supine, squeeze proximal tib and fib together, then continue distally to malleoli + if pain reproduced along fibular sharft if fibular #, along distal tibiofibular joint = syndesmosis sprain, injury more severe if pain more proximal
31
How would the shuck / cotton test be carried out and what does it assess?
Assesses syndesmosis instability with diastasis Supine, slight knee flexion and ankle over plinth, stabilise distal tibia and fibula one hand, lateral translation force to foot with other hand positive test is demonstrated when there is lateral translation indication syndesmotic instability, clunk heard or translation greater than 3-5 mm
32
What are the goals for syndesmosis treatment in 1st 2 weeks
Increase ROM, decrease pain and swelling, protect ligaments
33
What are the goals for treatment in 3 weeks onwards for syndesmosis injuries
Restore normal ROM Strengthen ligaments and supporting muscles Training to improve endurance and balance
34
What is the long term goal for syndesmosis injuries
Prevention of reinjury
35
what are the components for education with syndesmosis injuries
WB protocol Advice against vigorous physical activity until FWB and dynamic balance is normal gair training for crutch use or boot /brace use falls risk RICE NSAIDS in short term (pain management)
36
What are likely exercises for syndesmosis injuries
first 2 weeks: AROM flexion, alphabet, DF/ PF etc week 3-4: Standing stretch, seated DF stretch with theraband, double heel calf raise to single heel calf raise Progressive weight bearing progressing to treadmill use Progress to jogging, cycling, agility, jumping and sport-specific drills
37
What manual treatments may be wanted for syndesmosis injury?
PA movements of talocrural joint and subtalar joints with passive stretching to help stiffness
38
What is the epidemiology of achilles tendinopathy
52% of runners experience in lifetime risk factors as women, black individuals, higher BMI, middle aged middle-distance/long-distance runners 9% in dancers, 5% in gymnasts
39
what is the aetiology for achilles tendinopathy
prior tendinopathy or fracture Higher BMI greater running stiff achilles tendon increases risk precise cause unknown High BP Family history inappropriate footwear (elderly) Type II diabetes
40
What is the key anatomy affecting achilles tendinopathy
2 types, insertional = between tendon and bone, midportion is >2 cm from insertion Achilles tendon stems from gastroc and soleus at bottoms of calcaneus Achilles tendon is surrounded by paratenon that is an elastic sleeve to allow free movement blood supply to tendon poor, but supplied through paratenon, leads to slow healing rate post trauma
41
What is the suggested cause for achilles tendinopathy
Excessive overburdening on the tendon
42
What are the symptoms of achilles tendinopathy
Pain appearing when overburdened localized to tendon swelling and pain not as common tendon can appear to change in outline tendon will have a sensitive zone, situation dependent
43
What is the tendon continuum
Reactive tendinopathy, tendon disrepair, degenerative tendinopathy cycle back and forth
44
what are possible conditions for differential diagnosis with achilles tendinopathy
- Plantar fasciitis - Calcaneal fracture stress - Heel pad syndrome - Haglund deformity - Sever's disease - Posterior ankle impingement - Medial tendinopathy - Retrocalcaneal bursitis - Sural nerve - Lumbar radiculopathy - Ankle OA - Deep vein thrombosis - Partial Achilles tendon rupture
45
What would be conducted in an objective ax for achilles tendinopathy
Observation □ Atrophy is an important clue to the duration of the tendinopathy and present with chronic conditions □ Swelling, asymmetry and erythema in pathologic tendons are often observed in examination ROM, strength and flexibility testing Palpation = localized tenderness
46
Special tests for achilles tendinopathy?
royal london hospital test
47
How would the royal london hospital test be conducted?
Find maximally tender portion of tendon DF actively, palpate same region + test if less tender in dorsiflexion
48
What education may an achilles tendinopathy patient need
Should not completely rest Continue recreational activity within pain tolerance counsel on theories of mechanical loading, modifiable risk factors e.g. BMI and shoe wear, typical time course for recovery from symptoms controlled tendon loading
49
what observations should be made in an ankle assessment
static postures dynamic postures specific areas of interest swelling, muscle form and deformity at joint
50
what is the ideal posture in lateral, anterior and posterior views
Does line of gravity run through greater troch, posterior to patella, anterior to lateral (lat view) Pelvis level, femurs straight, patellaw level and straight, knees straight, ankle malleoli level, foot arches present and equal, feet rotated laterally (ant view) level gluteal folds, level popliteal folds, achilles tendons vertical, calcanei vertical
51
what do pes planus and pes cavus mean
flat feet, excessive arched feet
52
what muscle tests should be done on ankles
isometric: dorsiflexors plantarflexors invertors evertors
53
what are the ligament tests for the ankle
anterior drawer test medial talar tilt lateral talar tilt
54
how is the anterior drawer test carried out
tests laxity in anterior talofibial ligament prone position, leg bent up, stabilise distal tib fib and move anteriorly or sitting edge of plinth, create 10-15 degree plantar flexion and stabilise tib-fib, pull anteriorly postitive increased anterior translation, and dimple may appear
55
How would a medial talar and lateral talar tilt be conducted
tests deltoid complex on ligaments on the medial side and calcaneofibular ligaments on lateral side EIther in prone with knee flexed 90 degree or SOEOB, originally in slight plantar flexion, if in prone can use both hands to hold foot in varying degrees of flexion the test is positive if there is pain or theres excessive gapping
56
What are the possible injuries to the peroneum
Peroneal retinaculum or peroneal tear
57
What is a peroneal retinaculum tear
peroneal tendons are secured by superior and inferior peroneal retinaculum, ankle sprain can tear the superior retinaculum
58
What occurs in a peroneal dislocation
Peroneus longus is dislocated, producing instability
59
how is the peroneal longus dislocation test carried out?
Pt in prone with knee flexed to 90, pt asked to actively PF and evert against resistance, palpate the tendon whilst carrying out, tendon will sublux round malleolus
60
How are calf muscles measured in length?
Knee to wall test Pt with foot on floor, lunges forward to bring knee to the wall, can move foot back to require pt to maximally DF, max distance is recorded, and carried out on other leg Muscle length testing can also be carried out using a goniometer, with 10 degree DF normal for gastroc and 20 degrees normal for soleus

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