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MSK > Lower Leg & Ankle Complex > Flashcards

Lower Leg & Ankle Complex Flashcards

1
Q

Lateral (Inversion) Ankle Sprain

Description

A
  • Tearing of the ligaments on the outside (lateral) part of the ankle
  • Very common injury
  • May involve one or more ligaments on the lateral ankle
  • Ligaments of lateral ankle: ATFL, CFL, PTFL
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2
Q

Lateral (Inversion) Ankle Sprain:
Etiology

8

A
  1. Involves traumatic incident
  2. Common MOI is PF + inversion
  3. Jumping & landing on uneven surface (ie basketball player landing on another foot)
  4. Running on uneven surfaces
  5. Increased risk of injury in individuals w/ weak peroneal mm (everters - NOT supporting you in that direction) & ankle instability likely d/t repeated strains
  6. Order of injury during PF + inversion = ATFL > CL > PTFL

Inversion + neutral = CFL
Inversion + DF = PTFL

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3
Q

Lateral (Inversion) Ankle Sprain:
S/S

(8)

A
  1. Acute onset
  2. Swelling/ inflammation
  3. May present with warmth on lateral ankle
  4. May present with bruising
  5. Lateral ankle pain - worse w/ inversion & WB (helps to stabilize a weight bearing joint)
  6. Tenderness on palpation
  7. May present with instability
  8. Decrease proprioception
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4
Q

The West Point Ankle Sprain Grading System

A

Criteria: Grade 1
1. Location of tenderness: ATFL
2. Edema & ecchymosis: Slight local
3. Weight-bearing ability: FWB or PWB
4. Ligament damage: Stretched
5. Instaility: None

Criteria: Grade 2
1. Location of tenderness: ATFL & CFL
2. Edema & ecchymosis: Moderate local
3. Weight-bearing ability: Difficult w/o crutches
4. Ligament damage: Partial tear
5. Instaility: Slight

Criteria: Grade 3
1. Location of tenderness: ATFL, CFL & PTFL
2. Edema & ecchymosis: Significant diffuse
3. Weight-bearing ability: Impossible w/o significant pain
4. Ligament damage: Complete tear
5. Instaility: Definite

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5
Q

Lateral (Inversion) Ankle Sprain:
Special Test & Other

2 + 3

A
  1. Anterior Drawer (of Ankle)
  2. Talar Tilt

Other:
1. Ankle Lunge Test (knee-to-wall)
2. Proprioception testing
3. Strength testing (ie heel raises)

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6
Q

Medial (Enversion) Ankle Sprain

(4)

A
  • Tearing of the ligaments on the inside (medial) part of the ankle
  • Much less common than the lateral ankle sprain d/t the fibula blocking excess eversion & the strength of the medial ligaments
    Fibular extends further fown the leg compared to medial malleolus
  • Dut to strength of deltiod ligament, medial ankle sprains are typically associated w/ an avulsion fracture
  • Ligaments of medial ankle: anterior tibiotalar, posterior tibiotalar, tibiocalcaneal, tibionavicular
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7
Q

Medial (Enversion) Ankle Sprain:
Etiology

(4)

A
  1. Involves traumatic incident
  2. Involves everison of the ankle
  3. Jumping & landing on uneven surface
  4. Running & cutting
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8
Q

Medial (Enversion) Ankle Sprain:
S/S

(8)

A
  1. Acute onset
  2. Swelling/ inflammation
  3. May present with warmth on medial ankle
  4. May present with bruising
  5. Medial ankle pain - worse w/ eversion & WB
  6. Tenderness on palpation
  7. May present with antalgic gait
  8. Decrease proprioception
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9
Q

Medial (Enversion) Ankle Sprain:
Special Test

(3)

A
  1. Anterior Drawer Test (of the ankle)
  2. Talar Tilt (Eversion Stress Test)
  3. External Rotation Stress Test

Other:
- Lunge Test (knee-to-wall)
- Proprioception testing
- Strength testing (ie heel raises)

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10
Q

Medial (Enversion) Ankle Sprain:
Interventions

A

PT Management:
- Manage pain
- Manage swelling
- Bracing/taping
- Crutches if necessary
- Strengthening
- Proprioception
- Restore ROM
- Cross friction massage as tolerated

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11
Q

High Ankle Sprain (Syndesmotic Ankle Sprain)

(5)

A

Less common but more diabling
- Tearing of the syndesmotic ligaments which connect the tibia & fibula
- Described as high ankle sprain d/t the location of the sprain being above the ankle (talocrural) joint
- Rarely occurs in isolation. Typically associated w/ deltoid ligament injuries or fractures of the fibula or medial malleolus
- May involve one or more ligaments of the “high ankle” (4)
- Ligaments of the high ankle: AITFL, PITFL, Interosseous membrane

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12
Q

High Ankle Sprain (Syndesmotic Ankle Sprain):
Etiology

(3)

A
  1. Involves traumatic incident
  2. External rotation of the foot - FORCED hyper ER
  3. Hyper-dorsiflexion - falling from a high height & land on their feet
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13
Q

High Ankle Sprain (Syndesmotic Ankle Sprain):
S/S

(8)

A
  1. Acute onset
  2. Swelling/inflammation
  3. May present with warmth on anterior ankle
  4. Anterior ankle pain
    Worse with ER of the foot & weight bearing
  5. Tenderness on palpation over syndesmosis & interosseous membrae
  6. May present with antalgic gait
  7. Decrease proprioception
  8. May present with widening of mortis on imaging
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14
Q

High Ankle Sprain (Syndesmotic Ankle Sprain):
Special & Other Tests

A
  1. External Rotation Stress Test
  2. Sqeeze Test

Other:
1. Ankle Lunge Test (knee-to-wall)
2. Proprioception testing
3. Strength Testing

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15
Q

High Ankle Sprain (Syndesmotic Ankle Sprain):
Intervention

A

PT Management:
- Manage pain
- Manage swelling
- Bracing/taping
- Crutches if necessary
- Strengthening
- Proprioception
- Restore ROM
- Cross friction massage as tolerated

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16
Q

Fractures:
Ottawa Ankle Rules

(3) Description & Specifcs

A
  • Guideline to help clinicians decide whether or not a patient should be referred for radiographic imaging
  • In the past, an excess amount of radiographs were ordered for foot/ankle injuries which were not required & resulted in negative findings
  • Radiographs can be costly, time consuming, & potentially harmful to pt
  1. Bony tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus
  2. Bony tenderness along the distal 6 cm of posterior edge of tibia/tip of medial malleolus
  3. Bony tenderness at the base of 5th metatarsal
  4. Bony tenderness at the navicular
  5. Inability to bear weight both immediately after injury & for steps during inital evaluation
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17
Q

MOI - Avulsion #

(2)

A
  1. Medial Ankle Sprain
  2. Peroneal brevis tendon pullong base of 5th MT
    Can contact eccentrically so hard that it pulls off a piece of bone
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18
Q

Achilles Tendinosis

Description & Classification

A

Degenerative changes to the Achilles tendon
Chronic Achilles tendinopathy may lead to thickening of the tendon

Classification:
Insertional: < 2cm from calacaneal insertion
Midsubstance: 2-6 cm from calcaneal insertion

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19
Q

Achilles Tendinosis:
Etiology

Extrinsic & Intrinsic

A

Extrinsic Factors:
Sudden & drastic change in training regime
- Training time
- Training Frequency
- Distance
- Intensity
- Surface
- Footwear - MAIN RISK (ie suddenly switching from high heeled shoe > flat shoe)

Intrinsic Factors:
- Age
- Reduced DF (tight RF mm = excessive strain)
- Foot pronation (static or dynamic)
- Weight gain

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20
Q

Achilles Tendinosis:
S/S

(10)

A
  1. Insidious onset
  2. Morning stiffness
  3. Decreased ankle DF
  4. Decreased strength in ankle PF (attachment of PF mm)
  5. Pain
    Increased w/ active/resisted PF, passive DF, or WB
    Decrease pain w/ walking about or applying heat
  6. Tenderness on palpation
  7. Antalgic gait
  8. Thickening of Achilles tendon
  9. May present with retrocalcaneal exostosis
    Also known as a “pump bump”, Haglund deformity, or Achilles heel bone spur
    Often seen in females when it was fashionable to wear pumps
    Often leads to retrocalcaneal bursitis
  10. May present with crepitus (if paratenonitis is also present)
    Inflammation of the tendon itself
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21
Q

Achilles Tendinosis:
Intervention

(8)

A
  1. Avoid aggravating activities
  2. Eccentric exercsies for PF (ie heel drops)
  3. Increasing shoe height & progressively decreasig heel height
    INC depth of shoe = taking load (stretch) off tendon
    UNLOADing & then progressively loading it back
  4. Stretching of PS - temporary analgesic affect BUT if it is aggravating it - stop - could be sensitizing the tissue
  5. Manage pain
  6. Taping
  7. Night splint
  8. Manage inflammation if paratenonitis or retrocalcaneal bursitis also present
    Any inflammation in the area > manage it
22
Q

Achilles Rupture

Description & Epi

A

A full tear (grade III strain) of the Achilles tendon
- Typically occurs ~2-6 cm proximal to calcaneal insertion

Epi:
- M>F
- Athletes in their 30s & 40s

23
Q

Achilles Rupture:
Etiology

(4)

A
  1. Direct trauma (ie direct blow or cut)
  2. Rapid or forceful concentric contraction (ie jumping)
  3. Eccentric overload (ie landing from a jump)
  4. Corticosteriod use - weakens connective tissue
24
Q

Achilles Rupture:
S/S

(8)

A
  1. Patient may report audible snap or tear at time of rupture
  2. Swelling
  3. May present with warmth surrounding tendon
  4. May present with bruising
  5. Obvious limp - use of PF are not connected = no engagement
  6. May present with palpable gap in tendon
  7. Gross decreased strength in PF (secondary PF may provide some PF in supine but not strong enough in standing)
  8. May present with pain
25
Q

Achilles Rupture:
Special Test

1

A

Thompson’s Test
Squeeze calf to see if foot PF
Good confirmation test

26
Q

Achilles Rupture:
Interventions

A

PT Management:
- Cast immobilization in maximal PF for 4 weeks, followed by 4 weeks of immobilization in gradually reduced amounts of PF
- Crutches (NWB)
- Progressive ROM & strengthening exercises following immobilization
- Proprioception exercies
HIGHER risk of re-rupturing

Surgical Management:
- Rupture repair (suturing of tendon)
- Immobilization post-op same as conservative approach. Strength & ROM may be difficult to regain after rupture repair
HIGHER risk of complications (as w/ any invasive Sx - infection)

27
Q

Sever’s Disease

Description & Epi & Etiology

A

A traction apophysitis at the calcaneal insertion of the Achilles tendon

Epi:
- Common overuse injury in growing children
- Typically occurs in ages 7-10 (d/t calcaneus not being developed yet)

Etiology:
- Repeated tension on growth plate of calcaneus
- Growth-spurt - tib/fib faster than mm are lengthening
- Over-pronation
- Increase incidence in sports that involve running or jumping (espeically on hard surfaces)

28
Q

Sever’s Disease:
S/S

(4)

A
  1. Heel pain (posterior-plantar side) - where achilles is attaching
    Worse w/ walking, running, jumping ~ when using / stretching the calf mm
  2. May present with antalgic gait
  3. Pain w/ pressure over medial & lateral calcaneus in the area of the growth plate
  4. May present with DEC passive DF
29
Q

Sever’s Disease:
Intervention

A
  1. Manage pain
  2. Decrease parameters of aggravating activity (ie freq, intensity, duration)
    Do not want to suggest STOPPING the activity completely - but modify activity to DEC pain
  3. Foot orthotics
  4. Stretching - INC mm length - TRUE lengthening = 5 mins or longer
  5. Heel lift = DEC amount of stretch
30
Q

Shin Splints & Classifications

A

The term “shin splints” has many different meanings.
It is commonly described as a non-specific umbrella term to describe pain along the tibia
- It is sometimes meant to refer to pain along the medial border of tibia & is synonymous w/ medial tibial stress syndrome (MTSS)

Classifications:
1. Periositis
2. Stress fracture - micro
3. Compartment Syndrome - fascial compartment w/ too much pressure

31
Q

Periostitis

A

Inflammation of the periosteum (outer bone), a layer of connective tissue surrounding the bone
- Thought to be d/t chronic pulling (traction) of the periosteym by the mm connecting to the periosteum w/ repeated activity

ANTERIOR Shin Splints (anterior tibial traction periostitis)
- Over use of the tibialis anterior, extensor digitorum longus, & extensor hallicus longus
- Pain over the proximal 2/3 of anterolateral aspect of tibia
- Pain w/ resisted DF & passive PF (Pain w/ anything that is contracting/stretching the TIB ANT)
Last 2 pt - usually not enough load to provoke symptoms

POSTERIOR Shin Splints (medial tibial traction periostitis)
- Overuse of tibial posterior mm
- Pain over the distal 1/3 of posteromedial aspect of tibia
Palpate: medial edge of tibia > go b/t calf & tibia > deep groove is where the TIB POST is = tender
- Pain w/ active supination (contracting) & w/ passive DF + eversion (stretching)

MOST COMMON

32
Q

What is the most common type of shin splint?

A

Posterior Shin Splint (medial tibial traction periostitis)

33
Q

Periostitis: Etiology

Extrinsic + Intrinsic Factors

A

Extrinisc Factors:
Sudden or drastic change in training regime
- Training time
- Training frequency
- Distance
- Intensity
- Surface
- Footwear
BIGGEST cause - more evidence

Instrinsic Factors:
- Over-pronation - TIB POST tendon is going on stretch (wraps under surface of medial side) > eccentrically loading it
- Muscle dysfunction (tib post vs anterior)
- Fatige
- Decreased flexibility = INC traction on area

34
Q

Periostitis: S/S

(3)

A
  1. Gradual onset
  2. Diffuse pain
    Increases w/ activity (until mm is warmed up)
    Decreases or dissapears w/ warming up & at rest
  3. Diffuse tenderness on palpation

TEMPORARY period after they stop running - starts to INC & then DEC again

35
Q

Periostitis: Interventions

A
  1. Avoidance of aggravating activities (take a break from running)
  2. Manage inflammation
  3. Manage pain
  4. Taping - approximate mm that is pulling towards the bone can be effective
    Tib post - rotate mm (calf) to MEDIAL side - mm closer to their insertion on the tibia = less pulling
  5. Orthotics
    POST = excessive pronation > orthotics would prevent foot from dropping > supporting medial longitudinal arch
  6. Stretching (when not aggravated) & soft tissue mobilization
  7. Strengthening (graduated w/ an eccentric focus)
  8. Walk-run program - progressively loading them ack up to get back to their activities
  9. Address alignment & biomechanical issues
36
Q

Stress Fracture

A

Overuse injury to the bone typically from repetitive loading leading to microdamage

37
Q

Stress Fracture: Etiology

Extrinsic & Intrinsic Factors

A

Extrinsic:
Sudden or drastic changes in training regime
- Training frequency
- Training time
- Intensity
- Distance
- Surface: MOST common more forgiving (grass) > hard surface
- Footwear

Intrinsic Factors:
- Cavus foot: high arch = less shock absorption = more stress on structures & tibia is the one to fail
- Overportnation - not getting shock absorption (going right into pronation)
- Overall limb & foot alignment - may lead to overuse & excess loading
Had this alignment all thier life - really is’s a chang ein load that is greater than capacity
- LLD - overloading short limb more

38
Q

Stress Fracture: S/S

(3)

A
  1. Gradual onset
  2. FOCAL pain
    Pain present w/ activity & rest
    Pain remains constant or slightly increases with activity - same pain during duration
    Worse at night
    Worse w/ impact activities - everytime they hit the ground = pain
  3. Tenderness on palpation over bone
39
Q

Stress Fracture: Special Test

1

A

Stress Fracture Test (tuning fork vibration)
- Make fork vibrate - touch the bone & this irritates the places w/ hairline #

Another test: use ULTRASOUND & crank it up - go over area w/ hairline fracture > pt will say it is painful - soundwaves are getting into the cracks in the bone & irritating it

40
Q

Stress Fracture: Intervention

A
  1. Inital period of rest
  2. Avoidance of aggravating activities
  3. Crutches if required
  4. Gradual progressive loading (walk-run program)
  5. Walk-run program

Stress # will NOT show up on an x-ray early on - pt would require a bone scan

WOLF’S LAW - a bone in a healthy person will adapt to its imposed demand.
- As we start adding load, it will adapt to that demand

41
Q

Compartment Syndrome

A
  • Increased pressure within a fascial compartment of the lower leg which contrains mm, nerves, & blood vessels
  • May result in DEC BF (“choke them out”) > DEC tissue perfusion (INC fatigue) > INC ischemia > pain & potentially permanent damage (ischemic cell death)
  • The anterior & the deep posterior compartments are more commonly involved in comparment syndrome
  • Chronic Exertional Compartment Syndrome is increased pressure w/in fascial compartment of the lower leg during activity
    MM pump > more blood > INC swelling > INC pressure - all contained in a tight compartment
42
Q

What are the most commonly involved compartments in compartment syndrome?

A
  1. Anterior
    &
  2. Deep posterior
43
Q

Different Compartment Syndromes

Name, MM, Nerves, & Arteries/Veins

A

Compartment: ANTERIOR
Muscles:
- Extensor hallucis longus
- Extensor digitorum communis
- Tibialis anterior
- Peroneous Tertius
Nerves: Deep peroneal nerve (innervates the above mm)
- Cutaneous innervation: Webbing between the 1st & 2nd digit - lose/altered sensation
Arteries/Veins: Anterior tibial artery
S/S: Foot drop - nerve in DF are affected & nothing opposing PF

Compartment: LATERAL
Muscles: EVERTORS
- Peroneous brevis
- Peroneous longus
Nerves: Superficial peroneal nerve
-Cutaneous innvervation: Dorsum of the foot except for the webbing between 1st & 2nd digits
Arteries/Veins: Peroneal artery
S/S: May look like inverted foot b/c mm are not being opposed by the everters

Compartment: POSERIOR SUPERFICIAL
Muscles:
- Gastroc
- Soleus
- Plantaris
Nerves: Sural nerve (purely sensory - branch of tibial n.)
- Cutaneous innervation: Posterior lateral aspect of leg & the lateral foot & 5th digit (pinky)
Arteries/Veins:
- Posterior tibial artery
- Popliteal artery
- Peroneal artery
- Sural arteries

Compartment: POSTERIOR DEEP
Muscles:
- Tibialis posterior
- Flexor hallicus longus
- Flexor digitorum longus
- Popliteus
Nerves: Tibial nerve
- Cutaneous innervation: plantar aspect of the foot
Arteries/Veins:
- Posterior tibial artery
- Peroneal artery

BASED on the compartment syndrome S/S, you will know how to differentiate what compartment is affected b/c you know what nerve is affected - sensory & motor component

44
Q

Compartment Syndrome: S/S

(7)

A
  1. Gradual onset
  2. Diffuse pain
    Pain described as Severe cramping
    May see also w/ IC (NO neural component) - difference: IC is affecting the blood vessel directly - PVD impeding BF II ECP is from pressure from outside - tightening up area (NEURAL component)
    Increased with activity
    Decreased or dissapears w/ rest (significant decrease w/in several minutes)
  3. Severe cramping
  4. Tightness sensation
  5. May present w/ motor weakness
  6. May present with altered or absent sensation
    5-6 is if nerves are affected
  7. May present with vascular S/S (ie red, hot, glossy skin)
45
Q

Compartment Syndrome: Special Tests

(4)

A
  1. Compartment Pressure (gauge) test
    Needle w/ guage before activity & then reassess immediately post-activity (meausre pre-post)
  2. Pulse palation
  3. MMT
    Quick strength test pre-post exertion - compare
  4. Sensory testing
    Checking skin sensation pre/post (see if it is altered)
46
Q

Compartment Syndrome:
Intervention

A

PT Management:
- Rest
- Soft tissue mobilization

Surgical Management:
- Interosseous Membrane Release (fasciotomy) - cut & open up compartment

47
Q

Shin Splint - DDx

(4)

A
  1. Compartment Syndrome
  2. Perostitis
  3. Stress Fracture
  4. Tumor

SEE CHART on page.232-233

48
Q

Tarsal Tunnel Syndrome

A

Compression of the posterior tibial nerve through the tarsal tunnel
- MOST common nerve entrapment at the ankle
- The tarsal tunnel is created by the bone & flexor retinabulum

Tarsal Tunnel contians:
1. Tibial posterior tendon
2. Flexor digitorum longus tendon
3. Posterior tibial artery & vein
4. Tibial nerve
5. Flexor hallucis longus tendon

Superior > inferior
**tom, dick, & a very nervous harry*

49
Q

Tarsal Tunnel Syndrome:
S/S

(2 + 4)

A

Pain & paresthesia
- Burning, electrical shock nerve pain
- Plantar surfae of the foot (closer to heel)
- Increased w/ weight bearing activity
- Decreased w/ rest

May present with swelling in feet
- May further irritate TIBIAL nerve in tarsal tunnel

50
Q

Tarsal Tunnel Syndrome:

1

A

Tinel’s sign at the ankle
- Tap on the tunnel: located posterior to medial malleolus

MSK (13 decks)

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