Lower Extremity Injuries Flashcards
(140 cards)
1
Q
How should a suspected PROXIMAL FEMUR FRACTURE be managed ACUTELY?
A
- MEDICAL EMERGENCY
- Call EMS
- Treat for shock
- Splint before moving them
- test neurovascular structures periodically
- most require surgery
2
Q
If an acetabular fracture is missed - what can result?
A
- Avascular necrosis of the femoral head
3
Q
What would prompt URGENT HOSPITALIZATION with a Traumatic PELVIC FRACTURE?
A
- Disruption of the pelvic ring
- Abdominal organ injury or Hemorrhage
*no disruption of ring = treat based on symptoms
4
Q
What is a test used to diagnose Femoral shaft Stress Fractures?
A
- FULCRUM TEST (assessor’s arm under thigh; pushes superior to inferior at distal thigh; +ve = pain and apprehension)
5
Q
What types of femoral stress fractures are HIGH RISK? How are they treated?
A
- LATERAL FEMORAL NECK
- FEMORAL HEAD
- Surgical Stabilization OR STRICT non-weightbearing (until callous forms)
- typically occur at neck and are due to COXA VARA
6
Q
What is the typical TREATMENT for LE STRESS FRACTURE?
A
- PROPER diagnosis is important
- refer to MD
- Weight bearing restrictions (Non or limited)
7
Q
What is the typical CAUSE of Lower Extremity APOPHYSITIS? What are expected RTP timeframes?
A
- Chronic traction forces
- RTP =2-6 months (~3.1 month average)
8
Q
How should an uncomplicated ACUTE AVULSION fracture in the lower extremity be treated?
A
- TTWB for 1-2 months
- gradual progression of strengthening and stretching of impacted muscle as tolerated
- if displaced - may need surgery
9
Q
What anatomical factors increase the prevalence for hip LABRAL pathology?
A
- Coxa Vara
- increased center-edge angle (measures anterior coverage of femoral head by acetabulum)
- Retroverted femur
- Retroverted acetabulum
10
Q
How should LABRAL PATHOLOGY of the hip be managed ACUTELY?
A
- REST
- Protected weightbearing
- avoiding TRANSVERSE plane movement
11
Q
What are some DIFFERENTIAL DIAGNOSES for FAI?
A
- Osteitis pubis
- Athletic Pubalgia
- Lumbosacral Pathology
12
Q
Does FAI typically present with palpatory tenderness?Weak hip flexors and abductors?
A
- No
- Yes
13
Q
What are some STRUCTURAL DEFORMITIES that can contribute to hip instability?
A
- Shallow acetabulum (contributes to labral tears)
- Excessive acetabular retroversion or anteversion
- Inferior acetabular insufficiency
- Neck-shaft angle >140 deg (coxa valga)
14
Q
What is FOCAL ROTARY INSTABILITY of the hip?
A
- Laxity at ligamentous (often iliofemoral ligament) or capsular structure DUE TO repeated forceful rotation at hip (i.e.: golf, ballet, martial arts, baseball)
15
Q
What is the most common direction of HIP DISLOCATION? What is the MOI?
A
- ~85% POSTERIOR
- MOI = ant to posterior force on flexed and adducted hip
16
Q
How should a HIP DISLOCATION be managed ACUTELY?
A
- EMERGENT reduction (avoid Osteonecrosis)
* evaluate neurovascular status of leg (cutaneous nerve function, distal pulses - popliteal and dorsalis pedis)
17
Q
What is the HIP APPREHENSION sign? What is it used for?
A
- Passively EXTEND, ABDUCT, EXTERNALLY ROTATE = may report sensation of instability
- to test for atraumatic hip instability (hip is typically unstable in the posterior direction which is the most common direction)
18
Q
What activities or movements should the athlete with hip instability avoid?
A
- FORCEFUL HIP EXTENSION
- FORCEFUL ROTATIONAL LOADING
*these movements stress passive restraints
19
Q
What are some SPECIAL TESTS to determine atraumatic HIP INSTABILITY?
A
- FABER
- FADIR
- HIP IR >30 deg at 90 deg flex
- hip APPREHENSION sign
20
Q
What are some PRIMARY treatment focuses with REHAB for patients with atraumatic hip instability ?
A
- FOCUS ON NEURO RE-ED
- STRENGTHEN HIP ABDUCTORS AND ROTATORS (to assist in supporting limited passive restraints)
21
Q
Severe hip flexor injuries can lead to profound swelling which can cause what?
A
FEMORAL NERVE PALSY
22
Q
What can be predictive for adductor strains?
A
Relative strength deficits between hip abductors and adductors
23
Q
What is the most commonly injured hip adductor muscle?
A
- ADDUCTOR LONGUS
* has excellent blood supply - can rehab aggressively
24
Q
What muscles are indicated in ATHLETIC PUBALGIA (sports hernia)?
A
PUBIC ATTACHMENTS OF:
- RECTUS ABDOMINUS
- HIP ADDUCTORS
*often attributed to imbalance - strong adductors and weak abdominals
25
Some ATHLETIC PUBALGIA signs and symptoms include...?
- intense, deep groin/lower abdominal pain
- worse with: SPRINTING, CUTTING, RESISTED SIT UP TEST
- pain with RESISTED ADDUCTION and PALPATION TO PUBIC RAMIS
26
What are SURGICAL OPTIONS for ATHLETIC PUBALGIA?
- ABDOMINAL WALL REPAIR
- ADDUCTOR TENOTOMY
* rehab starts ~4 weeks post op
* avoid trunk extension and rotation to protect surgical site
27
What is the difference between INTERNAL and EXTERNAL SNAPPING HIP SYNDROME?
- INTERNAL = iliopsoas tendon snaps over iliopectineal eminence OR femoral head
- EXTERNAL (most common) = IT band or GLUTE MAX snaps over greater trochanter (sagittal and transverse movements)
28
For patients with EXTERNAL SNAPPING HIP, what muscle tends to be overactive AND what muscle tends to be underactive?
- Overactive = TFL
- Under active = Glute max
*Have been shown to glute eccentric weakness
29
What chance do partial ACL ruptures >50% have of complete rupturing?
>50% chance of progression to full rupture
30
At what point post ACL RECONSTRUCTION can you initiate jogging, hopping, jumping? What criteria must be met?
- 12 weeks
- STRENGTH AND ROM NORMALIZED
- NO LAXITY PRESENT - graft is secure
31
What is the MOI for the entire MCL (deep and superficial fibers)? What is the MOI for the SUPERFICIAL MCL?
- Entire MCL = knee extended
| - Deep fibers = knee flexed >20 deg
32
Injury to the deep fibers of the MCL are associated with what other structures?
ACL, medial meniscus, bone bruise, or osteochondral injury
*Deep fibers attach to medial joint capsule and medial meniscus
33
When valgus stress testing the MCL, what is the difference in laxity between grades 2-1+, 2-2+ and 3?
```
2-1+ = 0-5 mm laxity, end feel present
2-2+ = 5-10 mm laxity, end feel difficult to determine
3= no end feel (complete rupture)
```
34
How are MCL tears treated? What is the timeline for RTP?
- Almost exclusively treated CONSERVATIVELY
- get terminal KNEE EXTENSION ROM ASAP
- RTP = grade 1 = 7-10 days
Grade 2 = up to 3 weeks
* can brace (PT, MD dependent)
35
What is the POSTEROLATERAL COMPLEX region of the knee made up of?
- POSTERIOR JOINT CAPSULE
- LCL
- POPLITEUS TENDON
- POPLITEOFIBULAR LIGAMENT
36
What are some tests to aide in DIAGNOSIS of POSTEROLATERAL COMPLEX injuries?
- Knee Varys Test (laxity)
- Dial Test (laxity)- prone, flex knees, rotate tibias
- ER Recurvatum Test of Hughston (laxity)
37
What is the MOI for PCL injury?
- HYPERFLEXION
| - BLOW TO FRONT OF KNEE (TIBIA) WHILE KNEE FLEXED (dashboard)
38
What do POSTEROLATERAL COMPLEX injuries usually occur in conjunction with?
- LCL sprains
| - cruciate sprains
39
What are 3 tests to determine injury to the PCL?
- posterior sag sign
- posterior drawer test
- Clancy Step off test (thumbs palpate femoral condyle, IP joints palpate tibial plateau - which should be 1 cm in front of condyles; any deviation = positive)
40
What is the BIGGEST concern following PCL injury?
- RESIDUAL TIBIAL LAG (after reconstruction and surgery)
| * Avoid hamstring exercises the first 6-8 weeks
41
How is a DISLOCATED patella (usually laterally) RELOCATED?
- MOVING FLEXED KNEE INTO FULL EXTENSION (ACTIVELY OR PASSIVELY)
42
How should a DISLOCATED PATELLA be managed ACUTELY?
- IMMOBILIZE
- ICE
- TRANSFER for imaging (due to risk for fracture or osteochondral injury)
43
What are BRACING recommendations post LATERAL PATELLA DISLOCATION?
- Immobilize 3-4 weeks
| - post immobilization - progress to less restrictive brace with LATERAL BUTTRESS (limits lateral translation)
44
What is SURGICAL treatment of choice for LATERAL PATELLAR DISLOCATION if conservative treatment fails?
- MPFL repair or reconstruction
45
Why is a TIBIOFEMORAL DISLOCATION considered a medical emergency?
- Close proximity of NEUROVASCULAR structures in POPLITEAL FOSSA
- Can result in: vascular issue (loss of limb), or inability to walk (neurological compromise)
- IMMOBILIZE AND TRANSPORT
* sometimes it may REDUCE spontaneously = makes it difficult to diagnose
* if 3 or more ligaments have been injured = knee should be considered DISLOCATED (regardless of alignment)
46
What are signs and symptoms of TIBIOFEMORAL DISLOCATION acutely?
- Extreme pain
- Significant swelling
- Shock - WATCH FOR IT
47
How should TIBIOFEMORAL DISLOCATION be managed ACUTELY?
ACUTELY:
- Call EMS; Monitor neurovascular status (popliteal pulse, peroneal and tibial nerves)
- immobilize in EXTENSION for at least 4 weeks
48
How does knee MENISCAL injury type present differ as it's related to AGE of the patient?
- YOUNGER = meniscus (with ACL) = peripheral injury (more likely to heal intrinsically)
- OLDER = tears in less vascular area = less amenable to repair
49
What are the RTP recommendations post partial meniscectomy ?
- ~6-8 weeks
| * usually WBAT as tolerated immediately (no brace required)
50
What are the post-surgical requirements regarding weight-bearing status and brace use post MENISCUS REPAIR? What are ROM and strengthening restrictions? What is RTP timeline?
- ~4-6 weeks brace (locked into extension - depending on type and repair); WBAT or PWB (depending on repair, surgeon)
- flexion ROM <90 deg (first 6 weeks)
- strengthening progress as tolerated at 6 weeks
- RTP = 16-20 weeks
51
Differentiate between the 4 grades of OSTEOCHONDRAL INJURIES.
- Grade 1 = softening, swelling of cartilage
- Grade 2 = fissuring, fragmentation <0.5 inch
- Grade 3 = fissuring, fragmentation >0.5 inch
- Grade 4 = erosion down to subchondral bone
52
What are the signs and symptoms of OSTEOCHONDRAL INJURIES?
- PAIN and SWELLING with activity that relieves with rest
* no SPECIAL TESTS (best DX via radiographs, scope)
* symptoms may be MINOR until defect comes loose
53
What are the SURGICAL OPTIONS for OSTEOCHONDRAL INJURIES?
- Microfracture
- Osteochondral Autologous/Allograft Transplantation (OATs)
- Autologous Chondrocyte Implantation
- Debridement
- Lavage
54
What are the REHAB PRECAUTIONS post surgical intervention for OSTEOCHONDRAL injuries?
- Limited WB 4-6 weeks post (except with posterior patella, or in trochlear groove - can WBAT with brace in full extension)
- LOAD GRADUALLY
55
What is the path of the patella during knee movement from extension to flexion?
- TRANSLATES slightly medial as it enters the femoral condyles @20-30 deg flexion
- follows femoral condyle and TRANSLATES slightly laterally within the groove as it moves into greater flexion
56
What are some common activities that may EXACERBATE SYMPTOMS for those with PFPS?
- SQUATTING
- STAIRS
- KNEELING
57
How much should a PATELLA be able to be MEDIALLY TILTED?
15 deg past neutral
58
For what patient population would FOOT ORTHOSES be more effective in the treatment of PFPS?
- OLDER patients
- Those with FOREFOOT VALGUS or REARFOOT EVERSION
*Exercise may be better for YOUNGER patient
59
Why is it important to control KNEE PAIN?
- Pain inhibits QUAD muscle firing patterns
- Can lead to QUAD atrophy and loss of ROM
* Cryotherapy = effective at controlling pain
* Cryo + compression may be best method
60
What are the effects of INTRA-ARTICULAR EFFUSION on the KNEE joint and the surrounding musculature?
- inhibits QUAD muscle firing patterns
- detrimental effects on CARTILAGE (cartilage loss)
- irritation to the SYNOVIUM
* COMPRESSION = best for controlling/decreasing joint swelling
* E-STIM = immediately after injury = decreases edema
61
Why is it best to achieve JOINT (KNEE) ROM as soon as possible?
- Joint immobilization = results in fibrous adhesions in and outside of the joint = increases friction between soft tissue fibers and layers
62
What types of MENISCUS TEARS require a period of NON-WEIGHTBEARING post surgery?
- RADIAL TEAR
- DOUBLE RADIAL TEAR
*Non-WB = due to pattern of tear
63
With PROPRIOCEPTIVE AND NEUROMUSCULAR CONTROL exercises, what are some changes to increase complexity and challenge?
- Balance boards: double to single leg progression (differing planes of instabiity)
- INTERNAL PERTURBATIONS = moving uninvolved LE in different directions
- EXTERNAL PERTURBATIONS = resist force of perturbation, or regain balance after application of perturbation
- DISRUPTING CONSCIOUS THOUGHT = toss or kick ball while balancing
64
What is a FUNCTIONAL TESTING ALGORITHM regarding RTP?
- Clinical decision making model
- describes and evaluates OBJECTIVE DATA to determine readiness to progress to various stages of tests
- Allows full, safe, expedient return to sports
*Goal is to identify DEFICITS so they can be addressed
65
S/p ACL rehab - for RTP testing, how should Jump Testing be performed initially (single or double leg)? Why?
- Double leg
- WHY? = to shield affected side AND for increased comfort level
*ECCENTRIC LANDING stresses them most psychologically
66
What is the BROAD JUMP TEST criteria for progressing to single leg unilateral hop tests?
```
Male = jump 90-100% of their height
Female = jump 80-90% of their height
```
67
What is the criteria for successfully passing a BROAD UNILATERAL HOP TEST?
```
Male = jump 80-90% height
Female = jump 70-80% height
```
*AFFECTED LIMB should be within 10% of uninvolved limb
68
The LOWER EXTREMITY FUNCTIONAL TEST is utilized with RTP testing because it incorporates what factors?
- Progressive stress
- Acceleration Deceleration movements
- Has multiple forms of physical stress to the LE
- Simulates varied movements often seen in reactive sports
- Induce fatigue during testing
*LEFT= has been shown to identify deficits in pre-season injury screening
69
What are the most common sites for fracture in: the ankle, the foot, the mid foot, hind foot?
- ANKLE = bimalleolar
- FOOT = metatarsals (5th most often)
- MIDFOOT = cuboid
- HINDFOOT = calcaneus
70
What is a Maisonneuve fracture?
- Proximal fibula fracture with INTERROSEUS MEMBRANE and SYNDESMOSIS tearing
71
What are the Ottawa Midfoot Rules?
Radiographs are recommended if athlete has pain in mid foot and one of the following:
- TTP at navicular
- TTP at base of 5th metatarsal
- inability to bear weight (<4 steps)
72
What are the Ottawa Ankle Rules?
Radiographs are recommended if athlete has pain in malleolar zone and one of the following:
- TTP at posterior edge of lateral malleolus
- TTP at posterior edge of medial malleolus
- Inability to bear weight (<4 steps)
73
What is a common MOI for METATARSAL FRACTURE in sport?
- TWISTING
74
What METATARSAL, when fractured, may be at risk for delayed or non-union?
- 5th METATARSAL
- at metaphysic-diaphysis junction = watershed area AND due to biomechanics of transition between mobile diaphysis and rigid metaphysis
75
Differentiate the 3 zones of 5th metatarsal fracture
- Zone 1 = avulsion fracture of tuberosity (pull of peroneus brevis or lateral band of plantar fascia)
- Zone 2 = @ metaphysic-diaphysis junction
- Zone 3 = @ proximal diaphysis region (acute excessive load, or chronic loading = stress fracture)
*Operative management for 2 and 3 = best for athletic demand
76
How should a non-displaced metatarsal fracture be managed?
- 2-5 days in a cast
| - 2-4 weeks in a walking boot
77
How should a Jones fracture (Type 2 at metaphysic-diaphysis junction) be managed?
- conservative = non-WB in short leg cast for 8-10 weeks
| - surgical fixation recommended for athletes
78
What types of metatarsal fractures should be surgically fixated?
- those with >3-4 mm displacement OR >10 deg angulation
| * use of SHOCKWAVE or ELECTROMAGNETIC waves may enhance healing
79
What are RTP mean timeframes for : METATARSAL FRACTURE, ORIF 5TH METATARSAL, and NON-OP 5TH METATARSAL?
- 4.6 weeks
- 4-18 weeks
- 9-22 weeks
80
What is the most common site of lower limb stress fracture in runners?
- TIBIA (followed by femur, fibula, calcaneus)
81
What are signs and symptoms of STRESS FRACTURE?
- PAIN - during or after activity (relieves with rest initially)
- PAIN with ambulation (as injury progresses)
- PALPATORY PAIN
- LOCALIZED SWELLING
82
How should a LE STRESS FRACTURE be managed?
- LOAD and/or STRESS MODULATION (modified WB, and/or use of stabilizing orthotic depending on location)
- EDUCATE (i.e., nutrition, training volume, footwear/orthotics)
- CROSS TRAINING (to maintain CV fitness - V02 max 7% decline in first 2-3 weeks of stopping training)
- ADDRESS strength, ROM, flexibility deficits
83
What is a commonly accepted guideline for PROGRESSION or REGRESSION of an Athlete along a rehab/return to activity guideline?
- Presence or Absence of PAIN
84
When can RUNNING be initiated post LE STRESS FRACTURE? What VOLUME should be utilized when initiating running? What is a common PROGRESSION guideline?
- RUNNING PROGRESSION may be initiated once pain-free ADLs
- initiate with 1/3 to 1/2 of ATHLETES usual running distances and pace
- start with walk/run intervals (longer walking and progress to longer running)
- 10% progression per week
*Some recommend CYCLICAL TRAINING PROGRESSION (2 weeks higher level training to stress bone, 1 week reduced loading to allow for recovery)
85
What are typical RTP timeframes s/p LE STRESS FRACTURE?
- between 2-5 months (depending on severity and risk)
86
What are some PREVENTATIVE measures to protect against LE STRESS FRACTURE?
- IDENTIFY and CORRECT ENERGY BALANCE (nutrition, training workload, and rest days)
- GRADUAL ramping of weight bearing activity/training
- ORTHOTICS (custom fit or rigid)
87
What is the STEP TEST and what is it used to assess?
- assesses for STRESS FRACTURE RISK
- TEST = complete 30 step up/down reps per min
- 5 min = PASS
- if FAIL = 76% increase incidence of LE stress fracture OR 35% increase incidence in MSK injury
88
What is MEDIAL TIBIAL STRESS SYNDROME attributed to?
- BONY OVERLOAD or...
| - TRACTION periostitis at distal 2/3 of posteromedial tibia
89
How is MTSS managed?
- REST
- GRADUAL activity/running PROGRESSION
- MODIFY risk factors (nutrition, workload, rest days)
- MODIFY RUNNING MECHANICS
- ORTHOTICS (for those with excessive navicular drop)
*Recovery can be long, and recurrence rate HIGH
90
Where is the most common OC lesion in the ankle?
- TALUS (lateral > medial)
* can occur in up to 50% of ankle sprains
* non-traumatic (OC dessicans) can be from localized ischemia or repetitive micro trauma
91
With what athletes, injuries should a TALAR OC LESION be considered?
- recent ANKLE SPRAIN or FRACTURE
| - CHRONIC ANKLE INSTABILITY
92
What are signs and symptoms of TALAR OC LESION?
- pain and swelling with activity
- maybe limited ROM
- maybe locking, catching if displaced fragment
- if CHRONIC = deep ankle pain during or after loading activity (running, jumping)
93
How are TALAR OC LESIONS managed?
- NON-OP = rest, immobilization, Non WB ~6 weeks, gradual return to activity/WB
- PRP injections = shown to be effective
- OPERATIVE = micro fracture, ORIF, OATS, ACI
94
What is a common MOI for TURF TOE?
- INJURY to first MTP joint
| - MOI = HYPEREXTENSION of MTP (axial loading with ankle and first MTP in plantar flexed position)
95
What is the MOI for a High Ankle Sprain/Syndesmosis sprain?
- FORCEFUL IR of LOWER LEG over PLANTED FOOT with foot DORSIFLEXED and PRONATED
* isolated tears uncommon = usually with FRACTURE of one or more ankle bones
96
What are special tests for High Ankle Pain/Syndesmosis joint injuries?
- Squeeze Test (30% sen, 93.5% spec)
- External Rotation Test (20% sen, 84.5% spec)
* when POSITIVE = HIGHLY LIKELY
- SINGLE LEG HOP TEST (89% sen)
- "PAIN OUT OF PROPORTION FOR THE APPARENT INJURY" (79% spec)
97
Which SYNDESMOSIS injuries require surgical fixation? What is the RTP timeframe?
- Grade IIb (unstable) >2mm diastasis
- Grade III
* RTP typically ~9 weeks
* undertreatment can result in CHRONIC hindfoot valgus, chronic lateral tibiotalar overload
98
What are the signs and symptoms of MEDIAL ANKLE LIGAMENT INJURY?
- reported MOI (combined pronation and eversion, excessive ER of foot)
- Pain, swelling, hematoma over medial ankle
- TTP over medial ligaments
*uncommon to occur independently
99
What other injuries are MEDIAL ANKLE LIGAMENT injuries often associated with?
- MEDIAL and/or LATERAL MALLEOLUS FRACTURE
- HIGH FIBULA FRACTURE (MASIONNEUVE)
- SYNDESMOSIS INJURY
- LATERAL ANKLE LIGAMENT INJURY
100
What TEST is used to assess extent of JOINT INSTABILITY following medial sided ankle injury?
- EXTERNAL ROTATION STRESS TEST (gold standard) - stabilize tibia and externally rotate forefoot = look for amount of medial widening of ankle mortise
- use STRESS RADIOGRAPHY
101
What is the difference between Grade 2 and Grade 3 lateral ankle sprains?
- Grade 2 = ATFL involved only, >5 deg (<10 deg) loss in total ankle ROM, swelling <2 cm
- Grade 3 = ATFL and CFL +ve, >10 deg loss in total ankle ROM, swelling >2 cm
102
After an initial ankle sprain - how long after is recurrence high? What can be the result of recurrence?
- first 6-12 months
| - CHRONIC ANKLE INSTABILITY (functional instability, joint laxity, decreased physical activity levels)
103
When is SPECIAL TESTING for ankle ligament testing (ATFL and CFL) most effective?
- ~5 days after (after swelling resolves)
104
What cluster of tests/signs and symptoms increases the likelihood for determining POSITIVE LATERAL LIGAMENT SPRAIN?
Combo of:
- TTP at ATFL
- Lateral hematoma
- +ve anterior drawer (~5 days after)
*100% sensitivity, 75% specificity
105
What is one suggestion you can give an athlete after incurring a lateral ankle sprain, to prevent future sprains?
- WEAR ankle brace (lace up more effective than semi-rigid)
106
What are the RTP timeframes for lateral ankle sprains Grade 1, 2, 3a, 3b?
```
1 = 7 days
2 = 15 days
3a = 30 days
3b = 55 days
```
*days double with increasing severity
107
What is a Lisfranc injury?
- sprain or rupture of lisfranc ligament with or without fracture
- Lisfranc ligaments = Y-shaped PLANTAR ligament that goes from medial cuneiform to base of 2nd and 3rd metatarsals; DORSAL ligament that goes from medial cuneiform to base of 2nd MT; INTEROSSEUS ligament (between medial cuneiform and 2nd MT)
108
What bone is the "keystone" of the transverse arch?
- SECOND METATARSAL
109
What are the MOIs for a LisFranc injury?
- AXIAL LOADING and TWISTING over PLANTARFLEXED FOOT
| - SEVERE HYPERPLANTARFLEXION (i.e., falling backward with foot caught in stirrup)
110
What is "Fleck Sign"?
- avulsion fracture at the base of the 2nd MT (Lisfranc injury)
111
What are the signs and symptoms of a Lisfranc injury?
- diffuse mid foot pain, swelling
- plantar ecchymosis
- reported PAIN with walking down stairs
- TTP over dorsal aspect of TMT joints
- pain with PASSIVE motion at midfoot
- "GAP" sign = separation b/t 1st and 2nd toes (maybe)
112
How are "Lower Energy" Lisfranc injuries DIAGNOSED?
- combo of clinical exam AND
- weight bearing RADIOGRAPHS
*Lower energy injuries = typically seen in athletics
113
What are the stages of LOWER ENERGY Lisfranc injuries?
- Stage 1 = ligament sprain, <2 mm diastasis
- Stage 2 = ligament rupture, 2-5 mm diastasis
- Stage 3= ligament rupture, >5 mm diastasis, collapse of medial arch
* surgical stabilization recommended with 2 and 3
* UNSTABLE injuries need surgical stabilization otherwise POOR outcomes (persistent pain and disability)
114
What is a SPECIAL TEST to utilize to allow progression to GAIT out of the boot after LISFRANC INJURY?
- ABDUCTION STRESS TESTING = stabilize calcaneus, grab forefoot, PRONATE and ABDUCT
- if pain = +VE
- if no pain = -VE and can begin walking (~6-8 weeks after injury)
115
What SPECIAL TEST is used to allow return to INLINE athletic activities? Return to cutting/pivoting, uneven surface running?
- PAIN-FREE ambulation down several flights of STAIRS
- PAIN-FREE single leg HOP test x30 sec
*should expect RTP of >6 months for grade 2 and 3
116
What is the HALLMARK PRESENTATION of PLANTAR FACIITIS?
- PAIN with weight bearing (especially: in morning, WB after prolonged inactivity, or prolonged WB)
117
What are some common clinical findings in those with PLANTAR FACIITIS?
- TTP at proximal insertion
- restricted dorsiflexion, hamstring flexibility
- LLD has been observed in some
- +ve WINDLASS test
- Foot Posture Index (low score = supinated; high score = pronated)
118
What are some recommended treatment interventions for PLANTAR FACIITIS per JOSPT CPGs?
- TAPING (at gastroc of P. Fascia, OR to control pronation)
- ORTHOTICS (pre-fab or custom)
- NIGHT SPLINTS (for those with pain in the morning, 1-3 months timeframe)
- PHONOPHORIESIS (ketoprofen for pain relief)
- FOOTWEAR MODIFICATIONS (rocker bottom shoes, , shoe rotation through week with standing jobs)
119
What is the difference between ACUTE LOWER EXTREMITY COMPARTMENT SYNDROME and CHRONIC EXERTIONAL COMPARTMENT SYNDROME?
- ACUTE = emergent situation; fluid accumulation increases compartmental pressure = restricts vascular perfusion; can lead to tissue HYPOXIA and NECROSIS (if unrecognized and untreated)
- CHRONIC = believed to be due to increased compartment fluid volumes driving increased pressure; exertion based; gradual onset; bilateral in 82% of cases
120
What is CHRONIC EXERTIONAL COMPARTMENT SYNDROME a result of ?
- dramatic CHANGE in training workload (longer or more intense bouts)
121
What are the symptoms of CHRONIC EXERTIONAL COMPARTMENT SYNDROME ?
- LOWER LEG PAIN - progressive
| - PARESTHESIA or WEAKNESS (hallmark = when discontinuing activity)
122
How is CHRONIC EXERTIONAL COMPARTMENT SYNDROME diagnosed?
- clinical SIGNS and SYMPTOMS
- NEEDLE MANOMETRY
Pre-exercise pressure >15 mmHg
Immediately post exercise >30 mmHg
5 min post exercise >20 mmHg
123
What are some TREATMENTS for CHRONIC EXERTIONAL COMPARTMENT SYNDROME?
- ACTIVITY MODIFICATION/REST EDUCATION
- transition to FOREFOOT STRIKE (for runners)
- BOTOX (effective in anterior and lateral compartments)
*surgical COMPARTMENT RELEASE if conservative tx fails
124
What is the difference in NON-INSERTIONAL and INSERTIONAL ACHILLIES TENDINOPATHY?
- Non-insertional = ~6 cm from insertion; more common in older, less active, overweight
- Insertional = more in active population
125
What are 2 theorized sources of pain in ACHILLES TENDINOPATHY?
- Neo-vascularization with accompanying neo-nerves
| - Elevated GLUTAMATE levels in symptomatic tendon (though they remain elevated after pain is resolved)
126
Who is ACHILLES TENDINOPATHY most common in?
- men
- 30-55 years
- runners
127
What is a cardinal sign of ACHILLES TENDINOPATHY? What are the most ACCURATE tests for diagnosing it?
- PAIN and STIFFNESS after prolonged periods of rest (in acute stages)
- LOCATION of pain, and pain with PALPATION
128
What does current evidence suggest regarding EXERCISE and TREATMENT of ACHILLES TENDINOPATHY?
- LOAD matters most when treating TENDINOPATHIES (versus type of contraction)
* though ECCENTRIC exercises has the most evidence, (isometric, tendon neuroplastic training, heavy slow resistance training)
129
What is the "KISSING PHENOMENON" as it relates to rehabbing ACHILLES TENDINOPATHY?
- IRRITATION of the tendon just proximal to insertion when performing eccentric heel raises on step when stretched to end range
- with INSERTIONAL TENDINOPATHY = perform on flat surface to avoid this
130
What factors increase the likelihood of ACHILLES TENDON RUPTURE/TEAR?
- WATERSHED area (3-6 cm proximal to distal insertion); perfusion is also affected when this area is stretched
- COLLAGEN DEGENERATION = decreased strength in tendon with age
131
What are 2 MOIs for PERONEAL TENDON INJURIES?
- ANKLE INVERSION
- EXTREME ANKLE DF and EVERSION coupled with strong PERONEAL contraction = can tear PERONEAL RETINACULUM resulting in dislocation, tear, or instability of peroneal tendons
132
What test may detect TENDON SUBLUXATION in PERONEAL TENDON INJURIES?
- RESISTED DORSIFLEXION with SUBTALAR EVERSION
133
What is the "Peek-a-boo" sign?
- For observing subtle PES CAVUS deformity
| - Visualization of medial aspect of calcaneus while observing patient from anterior view
134
What does the Coleman Block Test assess?
- stand with LATERAL ASPECT of foot on BLOCK
- determines if PES CAVUS is coming from HINDFOOT (great toe doesn't touch floor) OR FOREFOOT (great toe touches the floor)
135
What is HAGLUND’S DEFORMITY?
Bony prominence/enlargement at posterior calcaneus due to REPEATED FRICTION
136
What sports is RETROCALCANEAL BURSITIS and HAGLUND’S DEFORMITY common in? Why does it occur in each?
- Figure skaters (skates stiff and/or poor fitting)
| - Runners (tight shoes, overtraining, altered biomechanics)
137
What sports is RETROCALCANEAL BURSITIS and HAGLUND’S DEFORMITY common in? Why does it occur in each?
- Figure skaters (skates stiff and/or poor fitting)
| - Runners (tight shoes, overtraining, altered biomechanics)
138
What is HAGLUND’S DEFORMITY?
Bony prominence/enlargement at posterior calcaneus due to REPEATED FRICTION
139
How is SEVER'S DISEASE caused?
- repeated TRACTION and SHEAR on CALCANEAL growth plate (excessive running, jumping)
140
What are some possible RISK FACTORS for SEVER'S DISEASE?
- increasing volume and/or intensity of training
| - pes cavus or planus (may affect loading and/or lead to stiffness of achilles = increasing stress on insertion)
