Ankle DDX

Question 1

tight compartment syndrome

history , diagnoses

Answer 1

caused by muscle expansion
- occurs when the tissue pressure within a closed muscle compartment exceeds the perfusion pressure and results in muscle and nerve ischemia.

Question 2

tight compartment syndrome

presentation

Answer 2

• severe cramping, diffuse pain and tightness
• pain decreases or disappears with rest
• pain increases with activity
• pain may increase or become present with warm up
• ROM is limited in acute phase
• Gradual to sudden on set
• sensation is sometimes is altered
• may be muscle weakness or paralysis
• stretching increases pain
• radiograph will be normal
• bone scan will be negative
• pulse is sometimes affected

Question 3

Special test for compartment syndrome

Answer 3

no special test for this syndrome

-restricted DF is positive

Question 4

Treatment for Compartment syndrome

Answer 4

• relieve pain
• limit pain causing activities
• manual therapy

-symptoms will not fully be relieved without surgical intervention

Question 5

L4 root lesion hx, dx aka radiculopathy

Answer 5

• pain in the lower back and hip radiating down the back of the thigh into the leg
• caused by damage to the lower spine which causes compression of the nerve roots which exit the spine
• compression can lead to tingling, radiating pain, numbness, paraesthesia and occasional shooting pains

Question 6

L4 root lesion presentation

Answer 6

• sensation diminished and pain on Medial aspect of lower leg, medial ankle, big toe
• restricted DF is positive
• patellar reflex may be diminished or missing
• knee extensors
• motor and sensory innervation may be diminished
• could be mistaken as “sciatica”

Pain and numbness would radiate down the buttocks to the back of the upper thigh but then could radiate around to the front of the shin. Symptoms typically would stop at the ankle and not descend into the foot (with rare exceptions).

Question 7

L4 root lesion special test

Answer 7

Femoral Nerve Stretch Test:
Tests for nerve root impingement at L2, L3, L4
-Test position:
-Patient prone with a pillow under the abdomen; examiner at side of patient
-Action:
Examiner passively extends hip while keeping knee flexed to 900
-Positive test:
Pain in anterior and lateral thigh

Question 8

L4 root lesion treatment

Answer 8

• Traction
• Thermal /cold therapy
• manual therapy (massage)
• Stretching, strengthening of low back muscles
• Preventing further injury or stress to the spine through improved ergonomics and posture

Question 9

tibialis anterior tendinitis hx, dx

Answer 9

• occurs due to activities placing large amounts of stress through the tibialis anterior muscle.
• These activities may include fast walking or running (especially up or downhill or on hard or uneven surfaces) or sporting activity (such as running or kicking sports). -Patients may also develop this condition following direct rubbing on the tibialis anterior tendon.
• This may occur due to excessive tightness of strapping or shoelaces over the tendon.
• subjective and objective examination
• X-ray, Ultrasound or MRI scan may be required to assist with diagnosis and assess the severity of the condition.

Question 10

tibialis anterior tendinitis treatment

Answer 10

soft tissue massage
ultrasound
stretching into PF
joint mobilization
dry needling
ankle taping
bracing
ice or heat treatment
exercises to improve strength, flexibility and balance
-ankle pumps
-inversion/eversion
activity modification 
a gradual return to activity program

Question 11

tibialis anterior tendinitis special test

Answer 11

Resisted DF

Question 12

tibialis posterior tendonitis (hx, pathology)

Answer 12

• occurs when the posterior tibial tendon becomes inflamed or torn
• the tendon may not be able to provide stability and support for the arch of the foot, resulting in flatfoot

-An acute injury, such as from a fall, can tear the posterior tibial tendon or cause it to become inflamed. The tendon can also tear due to overuse. For example, people who do high-impact sports, such as basketball, tennis, or soccer, may have tears of the tendon from repetitive use. Once the tendon becomes inflamed or torn, the arch will slowly fall (collapse) over time.

Question 13

tibialis anterior tendinitis imaging

Answer 13

MRI

Question 14

tibialis posterior tendonitis (hx, pathology)

Answer 14

• occurs when the posterior tibial tendon becomes inflamed or torn
• the tendon may not be able to provide stability and support for the arch of the foot, resulting in flatfoot

-An acute injury, such as from a fall, can tear the posterior tibial tendon or cause it to become inflamed. The tendon can also tear due to overuse. For example, people who do high-impact sports, such as basketball, tennis, or soccer, may have tears of the tendon from repetitive use. Once the tendon becomes inflamed or torn, the arch will slowly fall (collapse) over time.

Question 15

tibialis posterior tendonitis (treatment)

Answer 15

• orthotics and braces
• Surgery to remove the inflamed tissue or repair a simple tear
• eccentric strengthening exercises
• immobilization
• steroid injection
• rest
• ice
• NSAIDS

Question 16

tibialis posterior tendonitis (imaging)

Answer 16

?

Question 17

tibialis posterior tendonitis (treatment)

Answer 17

• orthotics and braces
• Surgery to remove the inflamed tissue or repair a simple tear
• eccentric strengthening exercises
• immobilization
• steroid injection
• rest
• ice
• NSAIDS

Question 18

tibialis posterior tendonitis (imaging)

Answer 18

MRI

Question 19

“Shin splint” (hx, pathology)

Answer 19

Shin splints are a common exercise-related problem. The term “shin splints” refers to pain along the inner edge of the shinbone (tibia).

Shin splints typically develop after physical activity. They are often associated with running. Any vigorous sports activity can bring on shin splints, especially if you are just starting a fitness program.

Can be caused by

• Irritated and swollen muscles, often from overuse
• Stress fractures, which are tiny breaks in the lower leg bones
• Overpronation or ‘‘flat feet” – when the impact of a step makes your foot’s arch collapse
• Weakness in stabilizing muscles of the hips or core
• Poor lumbar spine function

Question 20

rupture of tibialis posterior (hx, pathology)

Answer 20

Whenever the tibialis posterior muscle contracts or is stretched, tension is placed through the tibialis posterior tendon. If this tension is excessive due to too much force or repetition, damage to the tibialis posterior tendon may occur. This can range from minor tearing of the tendon with subsequent inflammation to a complete tibialis posterior tendon rupture.

Question 21

“Shin splint” special tests (findings, clinical prediction rules)

Answer 21

Shin Palpation Test
-squeeze the lower two-thirds of the lower leg, including the shin bone (tibia) and surrounding musculature, “with enough pressure to squeeze out a wet sponge.” If there’s any pain present, you’re positive on that test.

Shin Edema Test
-Along the lower two-thirds of the tibia, as shown, press your finger in and hold for five seconds. When you remove your finger, does an indentation remain behind? If so, you have “pitting edema”—basically an accumulation of fluid under the skin—and you’re positive for the test.

A positive result on the second test is much less common than on the first test—and it’s also a much more accurate sign that trouble (in the form of shin splints) is on the way. And the researchers also found one more key warning sign: the women in the study were three times as likely to develop shin splints than the men. What this means (strangely enough) is that the tests are better at predicting shin splints in men, since they’re less likely to develop them in the first place.

Question 22

rupture of tibialis posteriorspecial tests (findings, clinical prediction rules)

Answer 22

may be confirmed with an MRI scan or ultrasound

Question 23

“Shin splint” (imaging)

Answer 23

bone scan

Question 24

rupture of tibialis posterior (hx, pathology)

Answer 24

Whenever the tibialis posterior muscle contracts or is stretched, tension is placed through the tibialis posterior tendon. If this tension is excessive due to too much force or repetition, damage to the tibialis posterior tendon may occur. This can range from minor tearing of the tendon with subsequent inflammation to a complete tibialis posterior tendon rupture.

Question 25

rupture of tibialis posterior(presentation)

Answer 25

- pain on the inside of their foot, ankle and lower leg - unable to raise their heel in standing and may have a visibly flattened inner arch of the foot when compared to the normal side. - visible swelling or thickening of the inner lower leg or ankle

Question 26

peroneal nerve lesion treatment (conservative, surgical, therapeutic exercises)

Answer 26

Orthotics, including braces or foot splints, which may be custom-built into the patient’s shoe -PT for gait training

Question 27

tibial nerve lesion(hx, pathology)

Answer 27

Can be caused by : Having flat feet or fallen arches, which can produce strain or compression on the tibial nerve Swelling caused by an ankle sprain which then compresses on the nerve Diseases such as arthritis or diabetes which can cause swelling, thus resulting in nerve compression An enlarged or abnormal structure, such as a varicose vein, ganglion cyst, swollen tendon, or bone spur, that might compress the nerve - Often injured by pressure on the inner part of the ankle. - -Injury or disease of structures near the knee - The tibial nerve may also be affected by diseases, such as diabetes

Question 28

tibial nerve lesion (presentation)

Answer 28

``` Shooting pain in the foot Numbness Tingling or burning sensation Pain in the bottom of the foot and toes Weakness of foot muscles Weakness of the toes or ankle pt may have difficulty with toe flexion, inversion, and PF ```

Question 29

peroneal nerve lesion(hx, pathology)

Answer 29

aka foot drop -can be caused by an injury to the spinal cord or from other underlying diseases, such as amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), or Parkinson's disease. Sometimes, drop foot is a complication from hip replacement surgery, or other injuries ( knee or joint dislocation or fracture, herniated disc) These nerves provide sensation to the anterior (front) and lateral (side) parts of the legs and to the top of the feet. They innervate muscles in the legs which lift the ankle and toes upward (dorsi flexion).

Question 30

tibial nerve lesion treatment (conservative, surgical, therapeutic exercises)

Answer 30

Surgical -Tarsal tunnel release Orthosis (e.g., braces, splints, orthotic devices) may be recommended to reduce pressure on the foot and limit movement that could cause compression on the nerve. PT- pain control, ice, rest, limit functional activities

Question 31

peroneal nerve lesion special tests (findings, clinical prediction rules)

Answer 31

peroneal nerve test

Question 32

peroneal nerve lesion treatment (conservative, surgical, therapeutic exercises)

Answer 32

Orthotics, including braces or foot splints, which may be custom-built into the patient’s shoe -PT for gait training

Question 33

peroneal nerve lesion imaging

Answer 33

?

Question 34

tibial nerve lesion(hx, pathology)

Answer 34

Can be caused by : Having flat feet or fallen arches, which can produce strain or compression on the tibial nerve Swelling caused by an ankle sprain which then compresses on the nerve Diseases such as arthritis or diabetes which can cause swelling, thus resulting in nerve compression An enlarged or abnormal structure, such as a varicose vein, ganglion cyst, swollen tendon, or bone spur, that might compress the nerve - Often injured by pressure on the inner part of the ankle. - -Injury or disease of structures near the knee - The tibial nerve may also be affected by diseases, such as diabetes

Question 35

L5 (S1) nerve root lesions (presentation)

Answer 35

Without calf muscle strength, the length of stride on that leg will be shorter, creating a limp. With the activity of running, the stride length will be even shorter, making the limp more noticeable. Climbing and descending stairs will be noticeably more difficult with the weak leg. All athletic endeavors will be more limiting. - Weak PF - Numbness, paresthesias (pins and needles) and pain - Initial pain will occur in the buttocks and radiate down that leg through the back of the thigh, the back of the leg and the bottom of the foot.

Question 36

L4 (L5) nerve root lesions treatment (conservative, surgical, therapeutic exercises)

Answer 36

- Traction - Thermal /cold therapy - manual therapy (massage) - Stretching, strengthening of low back muscles - Preventing further injury or stress to the spine through improved ergonomics and posture

Question 37

L5 (S1) nerve root lesion special tests (findings, clinical prediction rules)

Answer 37

straight leg raise test | spine percussion

Question 38

tibial nerve lesion imaging

Answer 38

?

Question 39

L4 (L5) nerve root lesions(hx, pathology)

Answer 39

The L5 nerve innervates the tibialis anterior, the foot and toe dorsiflexor, the peroneal muscles and the gluteus medius muscle. Weakness of any of these muscles can create a pathological gait.

Question 40

Tibiofibular ligament (hx, pathology)

Answer 40

High ankle sprains occur from rotational injuries, much like ankle fractures. They are common in sports, especially impact sports. An external rotation, when the foot is turned towards the outside with respect to the leg, most commonly causes these tears.

Question 41

L4 (L5) nerve root lesions special tests (findings, clinical prediction rules)

Answer 41

- straight leg raise test | - spine percussion

Question 42

Tibiofibular ligament special tests (findings, clinical prediction rules)

Answer 42

Two important tests also include the “squeeze test” and the” external rotation test.” The squeeze test is performed by squeezing the leg just below the knee to see if pain radiates to the high ankle ligament area, which would suggest a high ankle sprain. With the external rotation test, the knee is bent and the ankle is placed in neutral or 90 degrees with the foot in relation to the leg, and the foot is turned to the outside. If there is pain at the syndesmosis or the high ankle ligament area, then this indicates injury.

Question 43

L4 (L5) nerve root lesions imaging

Answer 43

?

Question 44

Tibiofibular ligament imaging?

Answer 44

?

Question 45

L5 (S1) nerve root lesions (presentation)

Answer 45

Without calf muscle strength, the length of stride on that leg will be shorter, creating a limp. With the activity of running, the stride length will be even shorter, making the limp more noticeable. Climbing and descending stairs will be noticeably more difficult with the weak leg. All athletic endeavors will be more limiting. - Weak PF - Numbness, paresthesias (pins and needles) and pain - Initial pain will occur in the buttocks and radiate down that leg through the back of the thigh, the back of the leg and the bottom of the foot.

Question 46

L5 (S1) nerve root lesions treatment (conservative, surgical, therapeutic exercises)

Answer 46

- Traction - Thermal /cold therapy - manual therapy (massage) - Stretching, strengthening of low back muscles - Preventing further injury or stress to the spine through improved ergonomics and posture

Question 47

Tibiofibular ligament (hx, pathology)

Answer 47

High ankle sprains occur from rotational injuries, much like ankle fractures. They are common in sports, especially impact sports. An external rotation, when the foot is turned towards the outside with respect to the leg, most commonly causes these tears.