ankle diff

Question 1

Posterior

Answer 1

• Achilles Tendinopathy
  – insertional vs noninsertional
• Retrocalcaneal bursitis
• Gastrocnemius Strain
• Haglund’s Deformity
• Sever’s Disease

Question 2

• Heel Pain

Answer 2

• Plantar Fasciitis

Question 3

• Anterior

Answer 3

• Anterior Impingement
• High Ankle/Syndesmotic Sprain

Question 4

ACHILLES TENDINOPATHY non insertional

Answer 4

• Achilles Tendinopathy -Non insertional
• Overuse injury with gradual onset located paratenon 2-6 cm above Achilles insertion
• Tendonosis – degeneration of the tendon itself
• Peritendinitis – inflammation limited to peritendon, commonly resulting in thickening of this tissue

Patient Demographics
* Common ages: 20-40

• MOI: Overuse
• Risk Factors
• Less active person
• Decreased DF ROM and/of PF strength
• Pes cavus/forefoot varus
• Subtalar Jt hyper/hypomobility
• Activities involving repetitive jumping, running, or training errors/sudden increase in load

Question 5

Achilles Tendinopathy - Noninsertional
* Subjective/Objective Findings

Answer 5

• Pain/stiffness with aggravating activity
• Pain/stiffness may lessen with moderate
  activity/exercise
• Flexibility limitations into DF
• Painful PROM into DF, AROM into PF
• Tenderness to palpation above achilles insertion
• Poor PF endurance during heel raise

Question 6

Achilles Tendinopathy - Noninsertional

conservative treatment

Answer 6

• Tendon loading into submax pain threshold
• Reduction of impairments – gastric/soleus flexibility, anterior tibialis flexibility, subtalar hypomobility
• Orthotics/shoes to offload tendon
• Modalities for pain management

Question 7

Achilles Tendinopathy - Noninsertional

surgical treatment

Answer 7

Debridement of adhesions surrounding
tendon/peritendon

Question 8

Achilles Tendinopathy – Insertional

in general

Answer 8

• Defined as inflammation at tendon-bone
  interface
• MOI: repetitive trauma, overuse, often with a
  mechanical compression component (loaded
  DF/PF past neutral tendon compresses on
  calcaneus)
• Decrease in vascularity at insertion over time
  thought to be a proposed reason for
  susceptibility

Question 9

Achilles Tendinopathy – Insertional

Patient Demographics

Answer 9

• Common ages: 20-40 often older than non-insertional
• Often less active adults, obese

Question 10

Achilles Tendinopathy – Insertional

• Risk Factors

Answer 10

• More active person
• Decreased DF ROM and/of PF strength
• Haglund’s Deformity
• Pes cavus

Question 11

Achilles Tendinopathy – Insertional

Subjective/Objective Findings

Answer 11

• Morning stiffness/posterior heel pain
• Swelling increasing with activity
• Limited DF ROM
• Overall deconditioned, limited recreational activity

Question 12

Achilles Tendinopathy – Insertional

Conservative Treatment

Answer 12

• Offload Achilles tendon with adjusting training and utilization of orthotics/footwear
• Modalities for pain management
• Gradual introduction of load
• *Consider reduction of load past neutral to avoid
  mechanical compression of tendon
• Follow similar progression for noninsertional
  tendinopathy

Question 13

RETROCALCANEAL BURSITIS

defined by

Answer 13

Inflammation of retrocalcaneal bursa or
subcutaneous calcaneal bursa

Question 14

RETROCALCANEAL BURSITIS

MOI

Answer 14

Repetitive stress/pressure/friction from shoe wear
during activity

Question 15

RETROCALCANEAL BURSITIS

Patient Demographic

Answer 15

• Varies in age but often older with lower recreational activities
• Common in runners

Question 16

RETROCALCANEAL BURSITIS

risk factors

Answer 16

• Foot posture index at either end range
• Training errors – sudden increase in volume
• Uphill training for runners
• Obesity and lower fitness levels

Question 17

RETROCALCANEAL BURSITIS

Question 18

RETROCALCANEAL BURSITIS

Subjective/Objective Findings

Answer 18

• Pain with running, footwear use
• Potential swelling posterior heel
• Pain with DF PROM/AROM
• Palpation tenderness superior to insertion
• Pain with medial/lateral combined pressure to achilles tendon

Question 19

RETROCALCANEAL BURSITIS

conservative treatment

surgical treatment

Answer 19

• Conservative Treatment
• Change in footwear
• Heel lift to alleviate pressure
• Improve posterior chain flexibility
• Improvement of DF ROM to reduce
  mechanical compression
• Surgical Treatment
• Bursectomy – removal of inflamed bursa

Question 20

GASTROCNEMIUS STRAIN

defined by

Answer 20

Damage to the muscle tissue in the belly or at musculotendinous junction

Question 21

GASTROCNEMIUS STRAIN

MOI

Answer 21

• Sudden eccentric load greater than
  muscles capacity
• Jumping/running uphill/forceful
  change of direction

Question 22

GASTROCNEMIUS STRAIN

Patient demo

Answer 22

• 20-40 yrs old
• Common in weekend warriors, sudden
  increase in activity

Question 23

GASTROCNEMIUS STRAIN

risk factors

Answer 23

• Age/activity level
• Previous injury
• Decreased strength of gastric/soleus
  complex

Question 24

GASTROCNEMIUS STRAIN

subjective/objective

Answer 24

• AROM painful and limited DF
• PROM c/ OP into DF
• Painful PF – pain increases as resistive
  load increases
• Palpation painful above tendon often
  mid/upper muscle belly of gastroc

Question 25

GASTROCNEMIUS STRAIN conservative treatment

Answer 25

* Improve flexibility/blood flow for improved healing with manual therapy * Modalities for pain management * KT taping for additional support * Reduction of pain provoking factors * Gradual increase in load to PF

Question 26

SEVER’S DISEASE defined by: presentation/treatment:

Answer 26

Defined by: * Calcaneal Apophysitis – traction injury to insertion of achilles tendon * Average onset is 8-13 years of age, before growth plate has closed * Tendon stronger than immature bone, pathology occurs at the growth plate Presentation/Treatment * Commonly associated with introduction of a new activity during preteen years (basketball, running, soccer, etc.) * Treat with offloading of structures with orthotic/shoe wear * Reduction of pain provoking factors/activity * Disease is self-limiting – improves as growth plate becomes mature bone

Question 27

HAGLUND’S DEFORMITY defined by: presentation/treatment:

Answer 27

Defined by: * An abnormal prominence of the posterior superior lateral border of calcaneus Presentation/Treatment: * Can be congenital, or a result of poorly fitting shoes during sporting activity in adolescent years

Question 28

PLANTAR FASCIITIS (PLANTAR HEEL PAIN) Passive treatment

Answer 28

* Limited evidence for night splinting * Orthotic use for offloading tissue – typically correcting and supporting pronation of midfoot * Heel cup/tape - meant to reduce load on gastroc/soleus complex * Manual therapy/needling to posterior chain and foot intrinsic to improve mobility * Great toe extension and ankle DF stretching

Question 29

PLANTAR FASCIITIS (PLANTAR HEEL PAIN) Active treatment

Answer 29

* Strengthening of the plantar fascia via loading * Plantar flexion with big toe in extension * Improve balance of anterior/posterior musculature strength and flexibility * Neuromotor control progressing to proprioceptive training of foot intrinsics (toe yoga, arch holds, etc.) * (See "Foot Core" article in supplemental reading)

Question 30

PLANTAR FASCIITIS (PLANTAR HEEL PAIN) defined by: MOI:

Answer 30

Defined by: * Pain at the insertion of the plantar fascia MOI: * Load and capacity are not aligned * Often increase/spike in activity involving repetitive plantarflexion/change of direction * Can be chronic in nature or acute

Question 31

PLANTAR FASCIITIS (PLANTAR HEEL PAIN) risk factors

Answer 31

* Obesity * Prolonged standing/walking * Pes cavus/pes planus * Lack of gastroc/soleus flexibility * Overpronation * Lack of DF joint mobility * Weak foot intrinsics

Question 32

ANTERIOR ANKLE IMPINGEMENT defined by moi patient demo risk factors treatment

Answer 32

Defined by: * Boney or soft tissue compression with maximal DF MOI: * Repetitive/forceful DF, repetitive ankle sprains * Irritation to periosteum of talor neck and/or general synovitis or capsulitis in anterior ankle * Patient Demographic * Dancers, sports/activities where maximal DF is occurring or repetitive ankle sprains * Risk Factors * Limited DF mobility/flexibility * Recurrent Ankle Sprains * Treatment * Improve DF mobility at Talocural Joint * Improve Gastroc/soleus mobility * Improve end range strength of CKC DF * Surgical debridement may be indicated depending on severity and activity demands

Question 33

HIGH ANKLE SPRAIN/SYNDESMOTIC SPRAIN defined by

Answer 33

* Disruption of ligaments between tibia and fibula proximal to talocrural joint * Tissue indicated: * Syndesmosis * Deltoid ligament

Question 34

HIGH ANKLE SPRAIN/SYNDESMOTIC SPRAIN MOI

Answer 34

* Forceful ER of the foot, driving talus into the ankle mortise * Forceful eversion or dorsiflexion of the foot * Rupture or sprain of tibiofibular ligament and/or syndesmosis

Question 35

HIGH ANKLE SPRAIN/SYNDESMOTIC SPRAIN subjective

Answer 35

* MOI involving forced DF, EV, and/or ER * Pain located proximal to TC joint * Pain with weight bearing specifically in stance and terminal stance phase

Question 36

HIGH ANKLE SPRAIN/SYNDESMOTIC SPRAIN objective

Answer 36

* Pain with PROM into DF and Ev * Pain with tibio/fibular squeeze test * Pain with bump test

Question 37

HIGH ANKLE SPRAIN/SYNDESMOTIC SPRAIN treatment

Answer 37

* Primary goal to reduce swelling and reduction of pain provocative movements * Use of boot/brace to limit forceful talus into mortise and CKC DF during gait * Reduction of forced weight bearing and any activities that encourage spread of syndesmosis * Modalities/Manual therapy to decrease swelling and improve AROM/PROM * Gradual introduction of weight bearing and CKC DF activities, utilizing tissue healing timelines and patient pain response * Reintroduce bilateral movements and transition to unilateral * Follow similar POC as lateral ankle sprain as impairments normalize (proprioception/balance training, normalize functional movements, introduction to plyometrics)