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MSK II - FOOT and ANKLE > Foot and Ankle- Achilles Tendinopathy and Associated Conditions > Flashcards

Foot and Ankle- Achilles Tendinopathy and Associated Conditions Flashcards

1
Q

What is the prevalence of Achilles tendinopathy?

A
  • MOST frequently reported overuse injury
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2
Q

What population is Achilles tendinopathy MOST common in?

A
  • recreational/competitive activities
  • training> competition
  • 30-50 year olds
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3
Q

What percentage of runners end up with Achilles tendinopathy?

A

~10-20%

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4
Q

What are risk factors/etiologies for Achilles tendinopathy?

A
  • Limited calf flexibility that may lead to tendinopathy origins
  • calf weakness that may lead to overuse/ under supply
  • biological males and family hx
  • excessive EV/pronation
  • Abnormal tendon structure / prior injury
  • older age
  • obesity
  • systemic dz with persistent inflammation and poor blood supply
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5
Q

Why can excessive EV / pronation lead to Achilles tendinopathy?

A
  • may lead to tendipathy origins due to achilles attaching more to medial portion of calcaneus
  • Overuse may occur with impaired LQ control
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6
Q

What can impaired LQ control with excessive EV / pronation lead to?

A
  • hip neuromuscular deficits
  • balance deficits
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7
Q

What is excessive pronation?

A
  • earlier, extended and/or excessive combination of DF, EV and abduction
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8
Q

How can pronation become excessive if hypermobility/instability is present?

A

More commonly:
- tibfib or talocrural hypermobility/instability
- impaired LQ control, top-down influence
Less commonly
- subtalar or medial knee hypermobility

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9
Q

How can pronation become excessive if adjacent joint hypomobility is present?

A
  • limited talocrural DF may lead to midfoot and forefoot excessively EV and abd
  • limited knee ext may lead to excessive ankle DF
  • HIP WONT COMPENSATE, hip is IR when knee and talus both ER at heel/toe off
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10
Q

What can excessive pronation be associated with in the foot? leg and ankle? Knee and hip?

A

LQ conditions
- Foot: plantar fascitiis, tarsal tunnel, Morton’s, OA, hallux valgus
- Leg and ankle: Achilles tendinopathy, Sever’s, MTSS
- knee and hip: see prior notes

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11
Q

Why is older age a risk factor for Achilles tendinopathy?

A

more plastic, less elastic = more tension (tendinopathy origins)

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12
Q

What else should we consider when thinking about the etiology of Achilles tendinopathy?

A
  • training errors
  • environmental factors
  • improper shoes
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13
Q

Why is obesity a risk factor for Achilles tendinopathy?

A
  • OVERUSE, increased demand due to excess weight
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14
Q

What is an example of a systemic disease with persistent inflammation and poor blood supply that can contribute to Achilles tendinopathy?

A
  • DIABETES
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15
Q

What structure is involved with Achilles tendinopathy?

A

Achilles tendon

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16
Q

What are the pathomechanics of Achilles tendinopathy?

A
  • repetitive lengthening with compression from limited DF and/or excessive EV
  • Collagen fibril thinning/disorganization and fibroblast death
  • Thickened tendon
  • Ineffective force transfer
  • Impaired motor control
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17
Q

What can cause the non-collagen matrix to fill in with Achilles tendinopathy?

A
  • altered fluid movement leads to overheating
  • Increased nitric acid with persistent inflammation
    CELLULAR CHANGES
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18
Q

What can cause the tendon to thicken yet weaken with Achilles tendinopathy?

A
  • increase of non-collagen matrix
  • fat deposition
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19
Q

What are some functional questionnaires for Achilles tendinopathy?

A
  • Victorian Institute of Sport Assessment
  • Foot and Ankle Ability Measure
  • LEFS
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20
Q

What are symptoms of Achilles tendinopathy?

A
  • Gradual onset that limits WBing activity
  • Localized pain and stiffness
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21
Q

When does the localized pain and stiffness occur with Achilles tendinopathy?

A
  • Particularly after inactivity
  • Lessens with mild bout of activity
  • Increase with moderate to severe activity
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22
Q

What are signs we will find in observation of Achilles tendinopathy?

A
  • Achilles thickening
  • possible impaired LQ control and/or excessive pronation
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23
Q

What will we find with ROM with Achilles tendinopathy?

A
  • Possible pain and limitation with DF
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24
Q

What will we find with resisted/MMT with Achilles tendinopathy?

A
  • possible pain with PF, may be weak
  • possible hip and knee weakness
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25
Q

What will we find in accessory motion with Achilles tendinopathy?

A
  • possible talar hypomobility for DF
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26
Q

What are some special tests for Achilles tendinopathy?

A
  • Arc sign (high spec)
  • Royal london test (high spec)
  • Single leg heel raise
  • Single leg hip
  • Muscle length (gastroc)
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27
Q

What does the single leg heel raise help us determine with Achilles tendinopathy?

A
  • On a flat surface vs. incline - Plantaris and insertional injury if more pain on incline
  • For PF endurance: less reps vs. uninvolved side
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28
Q

What are we looking for with the single leg hop test for Achilles tendinopathy?

A
  • less reps or pain vs. uninvolved side
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29
Q

What muscle length are we concerned about with Achilles tendinopathy?

A

shortened gastrocs

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30
Q

What are signs with palpation with Achilles tendinopathy?

A
  • TTP 2-6 cm proximal to insertion; area of less blood supply
  • Achilles crepitis
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31
Q

What does it indicate if the more medial Achilles is painful with palpation?

A
  • the plantaris is involved
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32
Q

What is NOT indicated for Achilles tendinopathy?

A

REST

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33
Q

What is the BEST pt ed for Achilles tendinopathy?

A
  • Optimal stress is BEST within appropriate pain levels, which is mild pain during and up to 24 hours after
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34
Q

What other topics should we educate the patient on with Achilles tendinopathy?

A
  • weight management
  • shoe wear
  • timeline
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35
Q

What is the timeline/prognosis with Achilles tendinopathy?

A
  • ~80% improvement within 8-12 weeks once right treatment begins, doesnt include “calming it down”
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36
Q

What modality is useful for pain and function with Achilles tendinopathy?

A
  • IONTO with dexamethasone
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37
Q

What should we know about LASER for Achilles tendinopathy?

A
  • contradictory evidence
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38
Q

What should we know about shockwave therapy for Achilles tendinopathy?

A
  • support for more pain relief with ADLs when added to 4 weeks of exercise
  • NO indication on structure changes or return to sport
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39
Q

What should we know about bracing for Achilles tendinopathy?

A
  • neoprene sleeves on involved muscles are anecdotal
  • night splint - NOT beneficial and NO support, stretches the tendon and repeats causative stress
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40
Q

What should we know about taping along the tendon with Achilles tendinopathy?

A
  • taping, including kinesiotape, along the tendon to reduce pain is anecdotal and conflicting
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41
Q

What should we know about arch taping and foot orthotics for Achilles tendinopathy?

A

limited evidence
- arch taping may help predict orthotic benefit
- shock absorbing orthotic decreased rate of injury

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42
Q

What should we know about a heel lift for Achilles tendinopathy?

A
  • mixed support
  • BOTH SHOES
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43
Q

What should we know about dry needling for Achilles tendinopathy?

A
  • helpful for pain when ADDED to exercise, but questionable otherwise
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44
Q

What should we know about STM for Achilles tendinopathy?

A
  • MOSLY anecdotal
  • ASTYM helpful for motion when ADDED to exercise
45
Q

What should we know about gentle stretching for Achilles tendinopathy?

A
  • Weak but some recent support on pain
  • May be contraindicated due to higher tension / compression on tendon
46
Q

What are JMs used for with Achilles tendinopathy?

A
  • mobility and function
47
Q

What are the primary purposes with MET for Achilles tendinopathy?

A

tendon proliferation and stabilization (hip and lumbar)

48
Q

What is the MET perscription for Achilles tendinopathy?

A

Tendinosis prescription
- Isometric loading without compression from lengthening
- Isotonic loading without compression from lengthening
- Isotonic loading with compression from lengthening
- Isometric loading in weight bearing
- Plyometric loading

49
Q

What is there best evidence of with MET for Achilles tendinopathy?

A

varied muscle actions
- eccentrics only - Alfredson protocol ( 6-10 sec eccentrics)
- lower compliance rates with eccentric training
- heavy and slow concentric/eccentrics
- isometrics

50
Q

What are the ultimate parameters for MET for Achilles tendinopathy?

A

3 sets of 10-15 reps
- 3 sec phases of muscle actions
- heavy load but NOT during inflammatory phase

51
Q

Why would we do heel raises with the knee extended and flexed with Achilles tendinopathy?

A
  • Extended for the gastroc
  • flexed for the soleus
  • want to target both
52
Q

When do we progress MET resistance and activity with Achilles tendinopathy? such as?

A

≥ mild symptoms

  • add weight in hand or with a loaded backpack
  • leg press or heel raise machine
  • sitting or standing heel raises
53
Q

How often should we be doing the MET for Achilles tendinopathy?

A
  • at least 2x/week and keep up 6-12 weeks
  • recommended every other day
  • may need more recovery time between heavy loading in a non-athletic or older patient, possibly 72 hours
  • once symptoms return to normal pain levels, repeat exercises
54
Q

What is the recurrence rate of Achilles tendinopathy?

A
  • 27%
55
Q

What is the success rate like with Achilles tendinopathy?

A
  • MOSTLY normalized tendon structure and thickness
  • improved mechanical properties as well as cortical function
  • ~12 week recovery
56
Q

~80% of those with Achilles tendinopathy are recovered in how many months?

A

3-5 months of progressive loading at a 5 year follow up

57
Q

What are the success rates for eccentric exercises for athletes with Achilles tendinopathy?

A

82-100% mid-portion tendinopathy in athletes

58
Q

What is the success rate for eccentric exercises for Achilles tendinopathy in sedentary individuals?

A

60%

59
Q

What is the success rate for eccentric exercises for insertional tendinopathy?

A
  • ≤ 32%
60
Q

How many have mild pain remain with Achilles tendinopathy?

A
  • 20-45%
61
Q

What should we know about mid-portion injections with Achilles tendinopathy?

A
  • insufficient evidence for cortisone
  • emerging evidence for high volume sclerotherapy (prolotherapy)
62
Q

What should we know about insertional injections for Achilles tendinopathy?

A

guided cortisone effective for pain and function
- alternative option for lack of success with MET

63
Q

What population is a guided cortisone injection recommended for with Achilles tendinopathy?

A
  • non-athletic population
64
Q

What can also be done with Achilles tendinopathy as a MD rx?

A
  • achilles debridement
  • remove plantaris
65
Q

What is another term for calcaneal apophysitis?

A

Sever’s disease

66
Q

What is the prevalence of calcaneal apophysitis?

A
  • 9-12 years of age
  • biological males > female
67
Q

What is the etiology of calcaneal apophysitis?

A
  • growth with high activity
68
Q

What is the structure involved and pathomechanics of calcaneal apophysitis?

A
  • leg bone growth exceeds PF lengthening
  • increased tendon tension
  • growth plate is the weak spot as opposed to tendon in the adult
  • mostly inflammation
69
Q

What are complications with calcaneal apophysitis?

A
  • avulsion and/or premature closure
70
Q

what are risk factors for calcaneal apophysitis?

A
  • long or year-round sports
  • poor fitting shoes that lack heel cushion
  • training errors
  • shortened PFs
  • foot dysfunction such as pes planus or cavus
71
Q

What is the onset of calcaneal apophysitis?

A
  • gradual onset of heel pain with overuse
  • 60% bilateral
  • a pop can indicate an avulsion
72
Q

What are some signs with observation of calcaneal apophysitis?

A
  • poor shoe support/cushion
  • foot dysfunction such as excessive pronation or supination
  • impaired LQ control
73
Q

What are some signs with ROM of calcaneal apophysitis?

A
  • limited DF leading to greater tensile forces on growth plate
74
Q

What are some signs with resisted/MMT of calcaneal apophysitis?

A
  • possibly weak and painful PFs
  • weak DF
75
Q

What are some special tests for calcaneal apophysitis?

A
  • squeeze test on heel
  • sever’s sign - pain with heel raise
  • muscle length: shortened gastroc
76
Q

What are we looking for with palpation with calcaneal apophysitis?

A
  • TTP over “cap” of calcaneus
77
Q

What pt ed should we do with calcaneal apophysitis?

A
  • soreness rule
  • load management such as active rest or rest days
  • movement cues for LQ mechanics
78
Q

What PT rx should we do for calcaneal apophysitis?

A
  • pt ed
  • POLICED
  • “u” shaped foam upside down on achilles with ankle sleeve
  • Restore DF ROM/ accessory motion
  • Hamstring stetching
  • Orthotics
79
Q

How can we restore DF ROM and accessory motion with calcaneal apophysitis?

A
  • JM and STM
80
Q

What should we be careful with calcaneal apophysitis?

A
  • prolonged calf stretches
81
Q

Why do we do hamstring stretching with calcaneal apophysitis?

A
  • due to fascial connections with gastroc
82
Q

What orthotics are useful with calcaneal apophysitis?

A
  • arch suport for excessive pronation
  • heel lifts > arch supports
83
Q

What should we know about heel lifts for calcaneal apophysitis?

A
  • more effective at 2 months
  • equally effective at 12 months
  • gel heel cups with a lift work BEST
  • BOTH SHOES
84
Q

What is MET for with calcaneal apophysitis?

A
  • any impaired LQ control
  • caution with muscle/tendon attached to growth plate to avoid greater overuse
85
Q

What is the prognosis with calcaneal apophysitis?

A
  • 75% resolved at 1 month and 95% at 3 months
  • can be a recurrent and/or persistent problem
86
Q

When does the growth plate close with calcaneal apophysitis?

A

= around 14 years

87
Q

What is the prevalence of Achilles rupture?

A
  • MOST common in biological men ages 20-50
88
Q

Where does the Achilles typically rupture?

A
  • typically ruptures 3-4 cm proximally to the calcaneal insertion
  • may or may not be associated with previous tendinopathy
89
Q

What is the etiology of Achilles rupture?

A
  • acutely and typically during a sudden eccentric activity
  • gradual with tendinosis
90
Q

What are symptoms of an Achilles rupture?

A
  • sudden onset of severe pain with trauma
  • sounds and feels like you’ve been shot in your calf
  • significant limitations in PF and weakness, if any use
  • unable to walk well if at all
91
Q

What are signs of an Achilles rupture in observation?

A
  • ecchymosis and swelling
  • asymmetrical and antalgic gait at BEST, likely unable
92
Q

What is a sign of an Achilles rupture in ROM?

A
  • limited if any PF
93
Q

What will we find in our resisted/MMT with Achilles rupture?

A
  • weak and painful PF
94
Q

What are some special tests for Achilles rupture?

A
  • Matle’s (20-30 degrees PF)
  • Thompson’s (insufficient research) (squeeze)
95
Q

What will we find with palpation with Achilles rupture?

A
  • gap in tendon
96
Q

What is the PT rx for Achilles rupture?

A
  • POLICED
  • like Achilles tendinopathy
  • follow MD protocol
97
Q

What is the consensus on a protocol for Achilles rupture?

A

NO consensus

98
Q

What should we know about early rehab vs immobilization with Achilles rupture?

A
  • early functional rehab and WB does NOT increase re-rupture rate vs cast immobilization
99
Q

What should we do with Achilles rupture patients early?

A

Early mobilization and WB with orthoses

100
Q

At week 0-2 of Achilles rupture, what is our ROM?

A

none

101
Q

At week 0-12 of Achilles rupture, what is our orthosis doing?

A

fixed at 30˚ PF

102
Q

What is our WB status at 0-2 weeks with a Achilles rupture?

A

NWB

103
Q

What is our ROM on weeks 3-6 of Achilles rupture?

A
  • up to 30 degrees DF, free PF
104
Q

What is our orthosis doing at weeks 3-6 of a Achilles rupture?

A

30 degrees PF, 0 DF

105
Q

What is our WB status 2 weeks after a Achilles rupture?

A

FWB

106
Q

What is our ROM limitations from week 7 on after an Achilles rupture?

A

-unlimited

107
Q

What is our orthosis doing at week 7 after an Achilles rupture?

A
  • NONE
108
Q

What should we know about prognosis of an achilles rupture?

A
  • Many professional athletes dont return to prior levels
  • 1/3 of NBA and NFL players dont RTP at all

MSK II - FOOT and ANKLE (6 decks)

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