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Flashcards in CBL Sports Med Deck (35)
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Main ankle joints

Tibiotalar joint (true ankle joint)
- responsible for plantar and dorsi flexion

Talocalcaneal or subtalar (false ankle joint)
- responsible for inversion and eversion as well as shock absorption


Too man toes sign

3+ toes can be seen when looking at a resting patient from the posterior

Often a result of pes planus


Most stable position of tibiotalar joint

- superior dome of talus is wider anteriorly cause more contact with ankle mortise when rocking backward in dorsiflexion= better stability


Least stable position of tibiotalar joint

Plantar flexion
- superior dome of talus is more narrow posteriorly and makes less contact with the ankle Mortise when rocking forward and anteriorly during plantar flexion = less stable


Sprain vs strain

Sprain = abnormal stretch/tearing of a ligament

Strain = abnormal stretch/ tearing of a muscle or tendon


Why are inversion sprains more common than eversion?

Medial ligaments are stronger than lateral ligaments

In inversion, ankle is plantar flexed which is unstable


Grade 1 ankle sprain

Stretching or microscopic tearing of the anterior talofibular or calcaneofibular ligaments (usually)

Caused by forced inversion and plantar flexion

Clinical presentation:
- mild tenderness and swelling
- little or no function loss
- minimal pain
- no mechanical instability of ankle


Grade 2 ankle sprain

Partial or complete tear of the talofibular ligament and stretching of the calcaneofibular ligament

Clinical presentation:
- moderate tenderness and swelling
-moderate ecchymoses (brushing)
- tenderness when palpating
- some motion and function loss
- pain when weight bearing
- mild-moderate instability of ankle


Grade 3 ankle sprain

Complete Tears of both the anterior talofibular and calcaneofibular ligaments

Partial tears of the posterior talofibular ligament and tibiofibular ligament

Clinical presentation:
- severe tenderness and swelling
-severe ecchymoses (bruising)
- strong tenderness when palpation of the ligaments and surrounding structures
- loss of function and motion
- serious mechanical instability of ankle


Anterior drawer and Tamar tilt tests

Anterior drawer test: slight plantar flexion of ankle with cephalad hand stabilizing distal lower leg
Caudad hand translates foot forward from calcaneus
(+) =. More than 5-8 mm compared to uninsured ankle

Talar tilt test; slight plantar flexion of ankle with one hand stabilizing the distal tibia just proximal to the medial malleolus. Other hand applies a slow inversion force with palpation at the lateral talus.
(+) = more more than 10 degrees compared to uninsured side

Grade 1 sprain: (-) on both
Grade 2 sprain: (+) on anterior drawer test, (+) or equal on talar tilt test
Grade 3 sprain: (+) on both


Treatment of ankle sprains

- RICE and NSAIDs or acetaminophen when needed
- OMT can be used as long as its indicated
- PT should be started as soon as tolerated

Usually no surgery on lateral ankle sprains/strains however, can be done with medial ankle sprains/strains

Can use Velcro brace and/or walking boots when needed for support


High ankle sprains/syndesmoses injuries

Usually results from tearing the following
- anterior inferior tibiofibular ligament
- Posterior inferior tibiofibular ligament
- interosseous membrane

Clinical presentation:
- no fracture: pain with dorsiflexion
- w/ fracture: cant put weight on it


3 phases of treatment in high ankle sprain conservative treatment

*RICE and NSAID’s when needed in all phases*

1st: non-weight bearing wearing a boot for 5-7 days and passive ROM exercise without booth 3 times a day

2nd: wearing weight baring brace for as long as pain is present while hopping . Use gait and light proprioceptive exercises

3rd: once no plain on foot and ankle with hopping. Protected full-weight baring (usually like a wrap) start resistive exercise and multi-axial ankle movements


Perineal muscle strains and factors that increase likelihood of occurring

Muscle strains in the lateral ankle via an eversion ankle sprain

Predisposed factors:
- prior ankle injuries
- respected inversion ankle injuries
- pes planus
- walking w/ excessive eversion for whatever reason
- poor fitting athletic equipment

Clinical presentation:
- pain and swelling along lateral ankle
- feeling of weakness or instability
- snapping sensation along lateral malleolus if retinaculum is torn


Muscle tendons in the medial ankle

Tibialis posterior tendon (Most common one injured during medial ankle sprain)

Flexor digitorum longus tendon

Flexor hallucis longus tendon


Factors that lead to tibialis posterior muscle strains

Over use

High impact sports

People older than 40 yrs


Acute injury

Clinical presentation:
- pain along medial foot and ankle (worsens w/ activity and standing for prolonged time)
- swelling along medial foot
-pes planus (sprains cause longitudinal arch to drop, leads to lateral foot pain)


Testing for tibialis posterior muscle sprain and treatment

Stand on one leg and raise the heel of the stance leg.
(+) patient cant do this

- overall limited flexibility especially dorsiflexion

Treatment =
- RICE, acetaminophen and low impact exercises.
- PT and arch support as well


Medial ankle muscle tendons

Tibialis anterior tendon (most commonly injuried)

Extensor digitorum longus tendon

Extensor hallucis longus tendon


Factors that lead to increase likelihood of tibialis anterior muscle strains


High-impact sports

Running or jumping on hard surfaces repeatedly

Acute injury

Pes cavus

Clinical presentation:
- pain along anterior-lateral tibia and dorsum of foot
- swelling anterior-laterally
- pain that worsens w/ activity and walking
- dorsiflexion weakness


Plantar fasciitis

Pain located at the anterior portion of the calcaneus in the plantar foot along the aponeruosis

- obesity
- pregnancy
- long distance runners w/ tight calf’s
- prolonged time standing on feet
- being bare foot a lot
- more common in older than 40 and female


Plantar fasciitis clinical presentation and treatment

Clinical presentation:
- pain worse in morning or after prolonged inactivity. Pain will improve after walking
- pain worsens when climbing stairs
- flares with prolonged activity

- stretching of gastrocnemius/ plantar fascia
- orthotics
- steroid injections
-OMT or PT


Achilles’ tendon rupture

Loud audible pop after experiencing Achilles tendonitis.

- most often ruptures at the “watershed” area of the tendon (4-5 cm proximal to calcaneus)


Ottawa ankle rules

Rules for getting an xray for the ankle

1) ankle pain in the malleolar zone compoundered with one of 2-4

2) bone tenderness along distal 6 cm of posterior fibular or the tip of the lateral malleolus

3) bone tenderness along the distal 6 cm of posterior tibia or the tip of the medial malleolus

4) inability to bear weight w/ 4 steps immediately after injury and at the office


Ottawa foot rules

Rules for getting a foot x ray

1) foot pain in the mid-foot zone and one of 2-4

2) bone tenderness at the base of the 5th metatarsal

3) bone tenderness at the base of the navicular bone

4) inability to bear weight w/ 4 steps immediately after injury and in the office


Three ankle X-ray views

AP: slight overlap of tibia and fibula

Lateral: fibula overlaps with posterior distal tibia

Mortise: 20 degrees of rotation of the foot (no overlap of tibia and fibula


Maisonneuve fracture

Caused by forced external rotation of foot and ankle

Causes the following:
- fracture of proximal tibia (usually spiral)
- tear/disruption of the interosseous membrane and tibiofibular syndesmosis
- malleolar fracture (usually medial)
- rupture of the deep deltoid ligament

*Mid calf squeeze test and forced external rotation will elicit high pain*


Types of 5th metatarsal fractures





Avulsion fracture of the 5th metatarsal

Most common fracture of 5th metatarsal

Located at the styloid process of the 5th metatarsal

- pull from fibularis (peroneus) brevis
- foot/ankle hyper-inversion

Treatment: short leg weight baring cast/hard sole cast shoe or surgery


Jones fracture of the 5th metatarsal

Location: At the base of the 5th metatarsal at the metaphyseal-diaphyseal junction, proximal to the metatarsal cuboid junction

Causes: pull from Fibularis (peroneus) tertius
- foot/ankle hyper-inversion
- lateral motions of foot
- dancing on toes
- repetitive trauma

- non-weight baring cast for 6-8 weeks for minimally displaced. Otherwise surgery


Stress fracture of the 5th metatarsal

Location: proximal portion of the diaphysis of the metatarsal

- sudden increase in physical activity
- repetitive microtrauma
- overuse

- non-weight baring cast for 6-8 weeks
- surgery for athletes