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MSK Practical Exam > Ankle Pathologies > Flashcards

Ankle Pathologies Flashcards

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1
Q

What are the 3 lateral ankle ligament called?

A

Anterior talo-fibula ligament

Calcaneofibula ligament

Posterior talo-fibula ligament

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2
Q

What are the grades for a lateral ankle sprain?

A

Grade I, II, III

Grade II and III instability is present

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3
Q

What are the 4 deltoid ligaments called?

A
  1. Anterior tibiotalar ligament
  2. Posterior tibiotalar ligament
  3. Tibiocalcaneal ligament
  4. Tibionavicular ligament
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4
Q

What injuries are usually associated with deltoid ligament injuries?

A

Lateral ankle sprains

Fractures

Syndemosis injuires

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5
Q

What movement does the deltoid ligaments prevent?

A

Eversion

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6
Q

What are the clinical features to diagnose a deltoid ligament sprain?

A

Popping sensation

Pain & Swelling

Exclude tibialis posterior injury

MRI

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7
Q

Name the 2 peroneal muscles and there origin and insertion?

A

Peroneal brevis and longus

Origin - Shaft of fibula

Insertion - Base of 5th metatarsal

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8
Q

What is the function of the peroneal muscles?

A

Wrap around lateral malleolus like a pully

Eccentrically control inversion and everts ankle

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9
Q

What associated injuries are common with lateral ankle sprains?

A

Base of 5th metatarsal fractures and peroneal tendon dislocations

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10
Q

What is a common overuse injury for the peroneal muscles?

A

Tendinopathy

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11
Q

What is the clinical presentation of a peroneal injury?

A

Pain localised posterior to lateral malleolus and tracks to lateral hind foot = peroneal trochlea on calcaneus and cuboid tunnel under foot

Pain on resisted PF and eversion

Snapping tendon across lateral malleolus

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12
Q

What are the Ottawa Ankle Rules and what are the 4 areas to palpate?

A

Assessment for potential ankle fracture

  1. Distal posterior 6cm of the fibula
  2. Distal posterior 6cm of the tibia
  3. Base of the 5th metatarsal
  4. Navicular tubicle
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13
Q

Using the Ottawa Ankle Rules, when is an x-ray required?

A

Bone tenderness on 1 of the 4 bony areas plus the inability to take 4 complete steps

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14
Q

What factors may affect your clinical judgement for an x-ray using the Ottawa Ankle Rules?

A

If the patient has other distracting painful injuries

Diminished sensation in the legs

Swelling which prevents palpation

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15
Q

What are the different types of 5th metatarsal fractures associated with inversion sprains?

A

Starting from proximal to distal:

Tuberosity avulsion fracture

Jones fracture

Stress fracture

Shaft fracture

Head fracture

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16
Q

What 5th metatarsal fractures are most common with a peroneal brevis injury?

A

Tuberosity avulsion fracture

Jones fracture

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17
Q

What is the Weber Ankle Fracture Classification?

A

Regarding lateral malleolus fibula fractures

Type A - fracture distal to syndesmosis. Usually stable. Associated with inversion injuries.

Type B - Most common. Fracture at level of syndesmosis with variable stability. Associated with inversion injuries.

Type C - fracture proximal to syndesmosis and often associated with syndesmosis injury. DF and eversion mechanism.

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18
Q

If the medial malleolus is fractured as well as the lateral malleolus what treatment is required?

A

Open reduction and internal fixation (ORIF)

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19
Q

What are the different ways a syndemosis injury can occur?

A

Injury to:

Anterior inferior tibiofibula ligament

Posterior inferior tibiofibula ligament

Interosseous ligament

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20
Q

What is the treatment if any of the ligaments involved with syndesmosis injuries have ruptured?

A

Surgery

Injury to interosseous = cast and surgery

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21
Q

What sign indicates the need for syndesmosis testing?

A

Pooling of blood lateral and anterior foot

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22
Q

What are the signs and symptoms of syndesmosis injuries?

A

! Inability to hop

! DF and ER pain

! DF and ER foot planted mechanism

! Inability to walk

! Pain out of proportion

! Pain in shin or knee during mechanism

! Feeling of instability

More pain compared to an ATFL injury

Unable to weight-bare, especially downstairs

Localised tenderness around anterior inferior tibiofibular ligament

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23
Q

Where should you palpate for syndesmosis injuries?

A

Whole leg due to high force mechanism

Anterio-lateral over tibia

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24
Q

What are the 4 compartments of the lower leg?

A
  1. Anterior compartment
  2. Lateral compartment
  3. Deep posterior compartment
  4. Superior posterior compartment
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25
Which 2 compartments does compartment syndrome most likely occur?
1. Anterior (40-60%) | 2. Deep posterior (30-60%)
26
What is compartment syndrome?
Swelling that occurs within one of the compartment and affects the nerves, veins, muscles and arteries
27
What are the compartments divided by and why is this important?
Fascia which is not flexible
28
What is the effect of compartment syndrome on the nerves, veins, arteries and muscles?
Muscles - weakness Obstruct nerves, veins and arteries that lead to altered sensation and loss of blood flow (feleing of deadness)
29
What are the 2 pulses in the foot and ankle? And when would you tests for these?
Posterior tibial pulse Dosal pedis Compartment syndrome
30
What structures are within the anterior compartment?
``` Muscles Tib Ant Extensor digitorum longus Extensor hallucis longus Peroneus tertius ``` Vessles Anterior tibial artery and vein Nerve Deep peroneal nerve
31
What structures are within the lateral compartment?
Muscles Peroneus longus and brevis Nerve Superficial peroneal nerve
32
What structures are within the deep posterior compartment?
``` Muscles Flexor hallucis longus Flexor digitorum longus Tib post Popliteus ``` Vessles Posterior tibial artery and vein Peroneal artery and vein Nerve Tibial nerve
33
What structures are within the superficial posterior compartment?
Muscles Soleus Gastroc Plantaris Vessels Branch of tibial artery and vein Nerve Sural nerve
34
What area of the foot will a patient get numbness, pins and needles or deadness due to anterior compartment syndrome?
Between big toe and 1st phalanx
35
What area of the foot will a patient get numbness, pins and needles or deadness due to deep posterior compartment syndrome?
Heel and plantar fascia
36
What population is at greater risk medial tibial stress syndrome?
Runners, heavy boot workers (army) and agriculture
37
What factors increase the risk of someone getting medial tibial stress syndrome?
! Increase in training volume ! Altered running mechanics -contralateral pelvic drop and increased ankle eversion Increased High BMI Increased Navicular drop Greater ankle PF ROM Greater hip ER
38
What are the subjective indicators of medial tibial stress syndrome?
Recent change in training load Exercise aggravates symptoms and rest eases symptoms
39
How do you diagnose medial tibial stress syndrome?
Tender on palpation of the distal 1/3 of the medial tibia (of at least 5cm)
40
What is tarsal tunnel syndrome?
Tibial nerve gets compressed posteriorly and inferiorly behind medial malleolus
41
What are the structures of the medial ankle?
Medial malleolus Tom - Tib Post Dick - Flexor digitorum longus And - Posterior tibial artery Very - Posterior tibial vein Nervous - Tibial nerve Harry - Flexor hallucis longus Tom is anterior and Harry is posterior
42
Where does tib post insert?
Navicular tuberosity
43
What type of pain does tarsal tunnel syndrome cause?
Neuropathic pain
44
What would you find/do in an objective assessment for tarsal tunnel syndrome?
Tinels sign Muscle weakness Numbness distribution - follows the tibial nerve usually through medial arch of the foot Neurodynamic testing Palpation of the nerve
45
What is the subjective indicators of plantarfascitis?
Plantar medial heel pain: most noticeable with inital steps after a period of inactivity but also worse following prolonged weight bearing 1st thing in the morning is very painful Heel pain followed by a recent increase in weight bearing activity or change in footwear Common in people with jobs that have a lot of walking e.g. army and postmen People with poor foot biomechanics
46
How do you diagnose plantarfacitis?
Pain on palpation of the proximal insertion of the plantar fascia (medial point of calcaneus) Positive Windlass test
47
How do you differentiate between plantarfascitis and tarsal tunnel syndrome?
``` Plantarfascitis No numbness or paraesthesia Worst thing in the morning No night pain Usually a change in load Will get pain initially when walking after rest before pain decreases ``` Tarsal Tunnel Pain medial aspect of heel and arch Paraesthesia and numbness on plantar aspect of foot (but not always) Idiopathic (no change or cause) 80% Can report pain eases with walking after period of rest (no pain initially) Night pain
48
How does tibialis posterior tendinopathy or dysfunction present?
Medial ankle pain and can extend to medial foot Biomechanical/postural changes in the foot Most common biomechanical change = pronation (foot arch drop)
49
What is the management of tibialis posterior tendinopathy or dysfunction?
Correct foot posture Strengthen tib post and lower leg
50
What tests would you do for tibialis posterior tendinopathy or dysfunction?
Navicular drop test Foot posture index
51
What are the red flags specific to the lower limb?
Fracture Compartment syndrome Septic arthritis Cellulitis Deep vein thrombosis (DVT) Peripheral arterial occlusion disease (PAD)
52
What is important to consider regarding the association between foot biomechanics and pain?
Pain may cause poor biomechanics Poor biomechanics may cause pain Or no association
53
What is the most common mechanism of achilles ruptures?
Participation in power sports When someone goes to push off after being sedentary 40-45 years as people are sedentary over winter then start physical activity again
54
What style of training should you prescribe for prevention and return to sport for achilles ruptures?
Plyometrics
55
What is the patient history for achilles ruptures?
Feels like a kick in the back of the leg and audible bang
56
How do you diagnose achilles ruptures?
Level of gap in the tendon Thompson test
57
What is the mechanism of a gastroc tear?
Active PF with knee extension MTJ most vulnerable Common in sports
58
What is the clinical presentation of a gastroc tear?
40-60 years Sudden pain and pain on weight bearing Feel like being hit by a stick in the back of the leg Substantial swelling and potential extensive haematoma due to being a high vascular muscle
59
How does a gastroc tear present on assessment?
Pain and swelling around medial head Pain on active or passive DF Decreased PF power Palpable defect in medial belly of gastroc Thompson test is negative Often confused with DVT or Bakers cyst
60
What is the mechanism of a Lisfranc fracture?
Hyper PF
61
What is a Lisfranc fracture?
Fracture and/or dislocation of the metatarsal Most common is the 2nd metatarsal Can happen to the 3rd and 4th metatarsal The fractured metatarsal dislocates dorsally
62
What is the clinical presentation of a Lisfranc fracture?
Midfoot tenderness Midfoot swelling Midfoot instability and rotation pain ! Forced the head of the metatarsal into abduction and DF and this reproduces symptoms
63
What is the clinical assessment of a navicular stress fracture?
Overuse and repetitive trauma (foot sprains) Pain on explosive start/push off Tenderness on palpation of the navicular tuberosity X-ray not very useful
64
What is Morton's neuroma and the clinical presentation?
Tissue around the nerve thickens from irritation/compression Usually occurs in 3rd webspace between tarsals Pain, burning, paraesthesia underneath toes Related to change in running load More exercise the patient does, the worse the pain gets
65
How do you diagnose Morton's neuroma?
Usually occurs in 3rd webspace between tarsals Squeeze test - Grab heads of metatarsals 1-5 and squeeze Positive if it reproduces pain Ultrasound to confirm
66
What is the management of Morton's neuroma?
Steroid injection
67
Name the 2 joint lines of the foot?
Lisfranc joint line (cuneiform and metatarsals) Chopart joint line (Calcaneus with cuboid / talus with navicular)
68
Name the 4 ankle joints
Talocrural joint (distal tib and fib with the talus) Subtalar joint (Talus and calcaneus) Distal tib fib joint Midtarsal joint (Calcaneus with cuboid / talus with navicular)
69
What are the general red flags?
Hx of cancer Constant progressive unremitting night pain Unexplained weightloss Radiotherapy / Chemotherapy IV drug abuse Alcohol and drug abuse Long-term steroid abuse Osteoporosis Rheumatoid arthritis Anticoagulants Asthma Epilepsy Diabetes Cardiac and circulatory problems Hx of trauma Cauda equina Pregnancy Poor general health 5Ds & 3Ns - Diplopia, dysarthria, dysphagia, nystagmus, nausea, numbness
70
What are the special tests for the lateral ankle ligaments and the deltoid ligament?
Talar tilt Anterior drawer

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