Treatment of the Foot and Ankle Flashcards
(87 cards)
1
Q
What are the main classification systems (groups) of the foot and ankle?
A
- Mobilization (correction of mechanical dysfunction)
- Strengthening (stabilization)
- Postural
- Pain.
2
Q
In mobilization system, what types of movement related treatments we can offer?
A
• Manipulation • Mobilization • Mobilization with movement • Stretching (complimentary to the postural classification).
3
Q
Typically, a patient would fall into the pain classification if they are reporting pain greater than what number on the pain scale?
A
7/10. It suggests pain may be limiting patient function and should be treated accordingly.
4
Q
Exemplify an intervention to relieve concordant sign or priority impairment ok ankle and foot.
A
Thrust and non-thrust manipulation.
5
Q
What are the objectives of a thrust and non-thrust manipulation?
A
– Improve joint kinematics
– Improve capsular elasticity
– Decrease-intra-articular compression forces
– Improve ROM, pain, function.
6
Q
What precautions should we have with mobilization?
A
– Rheumatoid arthritis – Osteoarthritis or elderly patients – Radiotherapy – Prolonged corticosteroid use – Aspirin, anti-coagulant medications – Structural instability.
7
Q
Refer the absolute contraindications to a manipulation.
A
– VBI
– Malignancy of the spine
– No manipulation of the Cspine in patients with RA
– Spinal instability
– Fracture
– Positive neurological signs indicating compromise of spinal cord, cauda equina, or spinal nerve roots
– Total ligamentous rupture or acute repair of ligaments or tendons
– Psychological pain
– Not competent in performing the technique
– Source of symptoms cannot be determined.
8
Q
How long do we perform a mobilization?
A
Depends on:
– Goal of mob (Treating Pain we use grade I and II; Treating Stiffness we use grade III and IV)
– Which joint?
– In general, treat until you feel change in mobility or change in patient response.
9
Q
What happens with a deficient support of anterior talofibular ligament? Why manual therapy is important?
A
- Deficiency of the ATFL increases anterior translation, internal rotation, and superior translation of the talus.
- At 100% body weight, ATFL deficient ankles demonstrated a statistically significant increase in anterior translation of the talus compared to the intact ankle.
- These altered kinematics may contribute to the degenerative changes observed with chronic lateral ankle instability and lead to OA.
• This suggest the potential need for manual therapy to “realign” the positional faults in the ankle complex.
10
Q
What can happen to fibula with inversion sprains?
A
Sometimes fibula will get “stuck” in an inferior and anterior direction (fibular positional fault).
• Ankles with more swelling have the most anteriorly positioned fibula.
• Fibula positioned more anteriorly (about 2.5mm) in the chronically unstable ankle.
(Potential for manual therapy).
11
Q
Refer a manual therapy technique that can be helpful in patients with recurrent ankle sprain.
A
A study suggests that Mobilization With Movement (both the weight-bearing and non-weight-bearing) can improve posterior talar glide and dorsiflexion in individuals with chronic recurrent lateral ankle sprain.
12
Q
List the main mobilization/manipulation techniques used in the ankle complex.
A
- Lateral glides and eversion mobilization/manipulation
- Proximal tibiofibular joint thrust mobilization/manipulation
- Distal tibiofibular joint mobilization/ manipulation
- Rearfoot distraction thrust mobilization/manipulation
- Talocrural joint anterior to posterior mobilization/manipulation
- Alternate method of talocrural joint AP mobilization/manipulation.
- Mobilization With Movement in weight-bearing and non-weight-bearing.
13
Q
What cluster of findings may help to identify patients with a status of post inversion ankle sprain who would most likely benefit rapidly and dramatically from Manual Therapy + exercise?
A
- Symptoms worse when standing
- Symptoms worse in evening
- Navicular drop sup 5.0 mm
- Distal tibiofibular hypomobility
1 variable present – 50% prob of success
2 variables present – 78% prob of success
3 variables present – 95% prob of success
4 variables present – 56% prob of success of MT and exercice.
Even without the cluster of findings, 75% responds well.
14
Q
Exemplify exercices helpful in post inversion ankle sprain.
A
- Achilles tendon stretch, non-weight bearing with the knee extended
- Achilles tendon stretch, weight bearing
- Alphabet exercises (draw letters with foot)
- Ankle eversion self-mobilization
- Dorsiflexion self-mobilization.
15
Q
Which method looks to work better with inversion ankle sprain: Manual therapy plus exercise (2x/week x 4 weeks) OR Home exercise program (1x/week x 4 weeks)?
A
MTEX is superior to HEP in the treatment of inversion ankle sprains.
16
Q
Is it beneficial adding myofascial therapy to a treatment of Thrust and Nonthrust Manipulation and Exercise in patients with acute inversion ankle sprain?
A
A small study suggests greater improvements in pain and function, so the addition of myofascial therapy to a manually based program may further improve outcomes in patients post inversion ankle sprain.
17
Q
Refer the technique that can help in the suspiction of cuboid syndrome.
A
The cuboid whip manipulation followed by gentle massage. Patients properly diagnosed with cuboid syndrome who receive the cuboid manip may be able to return to sport within 1 or 2 visits without injury recurrence.
Attention - case series study!
18
Q
Which treatment condition seems to be more effective in treating plantar heel pain?
• Calf-stretching, A/P talocrural mobs, subtalar distraction manip
• Calf-stretching, A/P talocrural mobs, subtalar distraction manip, lateral subtalar joint glides, A/P – P/A first TMT joint
• Subtalar joint distraction manip,stretching, orthosis
• Subtalar joint distraction manip, stretching, foot intrinsics
A
In this case series study, all 4 patients reported a decrease in NPRS from an average of 5.8±2.2 to 0/10. So, in patients with plantar heel pain, an impairment based PT
approach emphasizing manual therapy demonstrated
complete pain relief and full return to activities.
19
Q
Which treatment seems better for plantar heel pain?
• Therapeutic ultrasound, ionto with dexamethasone, gastroc/soleus/plantar fascia stretch, intrinsic foot strengthening; 3x/day x 4 weeks
• STM, rearfoot eversion mobilization, ankle eversion self mobs, manual STM of plantar fascia, + gastroc/soleus stretches ; impairment based mobs at the hip, knee, ankle, foot.
A
- Manual physical therapy and exercise is superior to a combination of ultrasound, iontophoresis, and exercise for the management of patients with plantar heel pain.
- Both approaches demonstrated benefits; however, the magnitude of the benefit was more substantial with manual physical therapy and exercise.
20
Q
Does grade III sesamoid mobilisation helps in individuals with hallux limitus (turf toe)?
A
Sesamoid mobilization, flexor hallucis strengthening, and gait training should be included in the plan of care when treating an individual with hallux limitis.
21
Q
Describe a total intervention that can work in management of peroneal tendinopathy.
A
- Visit 1-2: rearfoot/forefoot posts, talocrural A/P, calf stretches, peroneal strengthening (At 1 month, pain had worsened)
- Visit 3: Lateral calcaneal glide. Immediate ability to perform 10 heel raises pain free
- Visit 4-7: Repeat lateral calcaneal glide, progress peroneal strengthening
- Visit 8: 0/10 pain with return to all previous activities pain free.
A lateral calcaneal glide, in combination with other manual techniques, and a structured HEP may be a useful treatment approach for a patient with peroneal tendinopathy.
22
Q
How to apply a rearfoot distraction thrust manipulation?
A
- Grasp the dorsum of the patient’s foot with interlaced fingers
- Provide firm pressure with both thumbs in the middle of the plantar surface of the forefoot
- Engage the restrictive barrier by dorsiflexing the ankle and applying a long axis distraction
- Pronate and dorsiflex the foot to engage the barrier
- Apply a high velocity, low amplitude thrust in a caudal direction. The clinician applies a distraction forces at the talocrural joint by shifting his or her weight away from the patient. The thrust is targeted purely into distraction.
23
Q
Describe the lying talocrural joint anterior to posterior mobilization.
A
- Use your left hand to firmly stabilize the lower leg at the malleoli
- Grasp the anterior, medial, and lateral talus with your right hand
- Apply an anterior to posterior oscillatory mobilization force to the talus.
24
Q
Explain the talocrural joint anterior to posterior mobilization with movement standing.
A
- The clinician grasps and supports the arch of the foot and applies a stabilizing force over the anterior talus
- A padded belt is placed over the patient’s distal posterior tibia and fibular and around the therapist’s buttock region
- The patient is guided into dorsiflexion of the involved ankle while the therapist produces a posterior to anterior force to the distal leg by pushing/moving backwards and pulling on the belt.
25
How to do lateral glides and eversion mobilization?
* Grasp the malleoli just proximal to talocrural joint with your left index finger, thumb, and web space, and use your forearm to stabilize the patient’s leg agains the table
* Place your right thenar eminence on the talus just distal to malleoli and grasp the rearfoot
* Use your body to impart a mobilizing force through your right arm and thenar eminence to the medial talus.
We also can do medial and subtalar glides.
26
Describe distal tibiofibular joint mobilization.
* Place the distal leg at the edge of the table. Use your leg to stabilize the foot and move the ankle into progressive dorsiflexion
* Grasp and stabilize the distal tibia with one hand
* Place your thenar eminence over the lateral malleolus and use your body to impart an anterior to posterior directed mobilizing force.
27
How to perform cuboid whip manipulation?
The patient assumes a prone position. The clinician grasps the foot by stabilizing the medial and lateral sides of the foot within his or her webspaces. The thumbs of the clinician are placed on the cuboid on the plantar aspect of the foot. The knee is flexed to approximately 70 degrees and the ankle is dorsiflexed to end range. In a quick movement, the clinician moves the knee into extension, the ankle into plantarflexion and supination. Concurrently with the physiological movements, the clinician also applies a plantar to dorsal thrust with his or her thumbs.
28
How should we manipulate proximal tibiofibular joint?
* Place your 2nd MCP joint in the popliteal fossa, then pull the soft tissue laterally until your MCP is firmly stabilized behind the fibular head
* Use your right hand to grasp the foot and ankle
* Externally rotate the leg and flex the knee to the restrictive barrier
* Once at the restrictive barrier, apply a high-velocity, low amplitude thrust through the tibia (direct the patient’s heel towards the ipsilateral buttock).
29
What are the main purposes of exercise therapy to the foot and ankle?
```
– Improve muscle strength
– Decrease muscle stiffness
– Decrease ground reaction forces
– Improve cardiorespiratory fitness
– Improve ROM, pain, function.
```
30
Refer the types of treatment to manage a posterior tibial tendinopathy.
* PRICEMM
* Foot orthosis to decrease pronation
* Posterior tibial tendon strengthening
* Consider immobilization in short leg cast for two to three weeks.
31
How to treat a peroneal tendinopathy?
* PRICEMM
* Foot orthotic
* Lateral heel wedge
* Eversion stengthening.
32
What are the treatment points to Achilles tendinopathy?
* PRICEMM
* Gastrocnemius and soleus stretching
* Eccentric strengthening program.
33
Summarise 2 differents protocols of exercise to an achilles tendinopathy.
```
• Protocol 1:
– 3 sets of 10 reps
– Increased load weekly
– Speed of movement changed daily
– 95% of patients reported symptom resolution in 6-8 weeks
```
• Protocol 2:
– Unilateral heel raises with no concentric component
– 3 sets of 15 reps, 2x/day, 12 weeks
There is strong evidence in support of eccentric loading to decrease pain and stiffness, and improve function in patients with Achilles tendinopathy.
34
A patient arrives to you with a med-tendon achilles pain. What should you evaluate and exclude?
Exclude rupture, evaluate peritendeinous structures.
35
How many time should we propose the Alfredson’s heel-drop exercise program to treat the achilles tendinopathy?
Begin Alfredson’s heel-drop exercise program 6-12 weeks (eccentric).
If respond: continue maintenance exercise 6-12 months.
* Based on research to date, the therapeutic exercise program to treat painful tendinopathy should consist of eccentric exercises that target the affected area with 3 sets of 15 reps 1-2x/day for at least 12 weeks
* It is ok to have pain while exercising but should not be progressive or disabling.
36
What if Alfredson’s heel-drop exercise program don't respond? List the alternatives.
(1) Continue exercise, evaluate and treat kinetic chain Modify load, consider GTN patch 6-12 weeks
(2) Continue exercise, add biomechanical assessment, massage and electrotherapy. Continue GTN patch 6-12 weeks
(3) Continue exercise, add pain-relieving adjuncts such as ESWT, CSI 4-6 weeks
(4) Sclerosing treatment 8-12 weeks
(5) Surgery.
37
How do we now if an athlete with achilles tendinopathy is ready to return to sport?
* Full range of motion and strength
| * Completion of full practice without pain.
38
What seems to work better in the treatment of posterior tibial dysfunction?
– Orthoses wear and stretching
– Orthoses wear, stretching, concentric progressive resistive exercise
– Orthoses wear, stretching, eccentric progressive resistive exercise.
The orthoses, stretching, and eccentric training group demonstrated the most improvement.
Early stage posterior tibialis tendinopathy responds well to a program of orthoses wear and stretching. Eccentric and concentric resistive exercises further reduce pain and function.
39
Is there effectiveness of exercise therapy and manual mobilization in acute ankle sprain and functional instability?
– There is moderate evidence that exercise therapy, including wobble board, is effective in the prevention of recurrent ankle sprains, both for patients with acute ankle sprain and with functional instability
– There is moderate evidence that exercise therapy has no effect on postural sway
– There is moderate evidence that manual therapy has an initial effect on dorsiflexion ROM after ankle sprains, but the clinical relevance may be limited.
40
Describe the acute phase of treatment after an ankle sprain.
Duration of 36-48 hours following injury.
* Refrain from activity detrimental to recovery
* Two hourly application of ice
* Compression to the foot, ankle, and leg
* Ankle strapped
* As swelling and bruising decreased, application of ice and time spent with limb in elevation was decreased. Ankle strapping maintained throughout this phase.
* Resting with the injured limb elevated
* Gentle free active ankle movements within the limits of pain.
* As the pain decreased, free active movements were progressed by increasing the range and frequency of movement and the number of repetitions of each movement.
• When the edema and acute pain had subsided, is an indication for progressing to the next treatment phase.
41
Detail the mobilizing treatment phase of an ankle sprain.
Mobilizing - Duration of 10-14 days.
* Mobilizing exercises for the foot and ankle
* Mobilizing exercises progressed by increasing range of movement, adding holds at end of range of movement, and increasing duration of holds
* Gentle their lower limbs strengthening exercises
* Strengthening exercises were added when subjects could easily undertake the mobilizing exercises
* Calf and heel stretches
* Stretches started in sitting and progressed to standing. Duration of the stretch increased
* Ankle strapping/taping
* Ankle kept strapped, and only removed 12 hours before each clinic appointment
• Progress to next phase, when subjects could cope with gentle resistance and, while standing, could tolerate equal weight through their lower limbs.
42
Expose the strenghtening treatment phase of an ankle sprain.
Strengthening - Duration approx. 10-14 days.
* Resistance bands for eversion and dorsiflexion
* Increased range of movement, length of holds at end of ROM, and strength level of band
* Body-weight resistance, standing
* Increased time spent in weight bearing position and decreased amount of support from rail
* One-leg standing on injured limb
* Increased amount of time, changed arm position, eyes closed
* Standing on balance board
* Decreased standing base, throwing and catching a ball, eyes closed
* Weight-bearing activities
* Progressed from walking to running, increased duration
* Ankle strapping
* As ankle stability improved, the ankle was strapped only during strenuous activity
• Subjects discharged from physical therapy intervention once they had obtained full ankle function and were able to cope with their daily activities.
43
Describe the time criteria to progress in the balance training phases.
* Standing with one foot (progress if it possible to do at least 30 sec)
* Standing with one foot, eyes closed (progress with 30 sec)
* Standing with one foot in an instable surface (progress to complete 30-60 sec)
* Standing with one foot in more instable surfaces.
* Add more difficulties (moving body parts, catching the ball, etc.).
44
Does balance training actually improves sensorymotor function in individuals with chronic ankle instability (CAI)?
– After 6 weeks of balance training, individuals with CAI demonstrated enhanced dynamic balance, inversion joint position sense, and changes in motorneuron pool excitability compared to healthy controls who did not train
– Balance board training protocols may produce improvements in the daily functioning of individuals with CAI.
– Treatment conditions: 3x/week x 6 weeks (50 minute session)
45
Is the wobble board training beneficial after partial sprains of lateral ligaments of the ankle?
Conclusion of the study: Wobble board training for a period of 12 weeks, beginning 1 week after the ankle sprain, was effective in reducing the number of recurrent distortions and in preventing functional instability of the ankle in patients with primary ankle sprains.
Treatment conditions:
• Treatment group: 12 week training program with a wobble board (15 minutes/day)
• Control: no training.
Results:
• 25% of the treatment group had recurrent ankle sprains versus 54% in the control group
• No differences seen in the edema between groups
• No difference in time to return to sport
46
What are the criteria to return to sport after an ankle sprain?
* Full Range of motion
* 80-90% of pre-injury strength
* Normal gait pattern
* Ability to perform sport-specific tasks including cutting and landing without pain or compensation because of the injury
* Completion of full practice without pain or swelling.
47
What techniques can be useful to treat plantar fasciitis?
* Dexamethasone or acetic acid delivered via iontophoresis
* Specific stretching
* Manual therapy
* Taping
* Custom foot orthoses.
• 80% will report resolution of symptoms within 1 year.
48
Which techniques are supported by evidence to treat plantar heel pain?
• There is moderate evidence that calf muscle and/or plantar fascia specific stretching can be used to provide short-term (2-4 months) pain relief and improvement in calf muscle flexibility.
• There is moderate evidence that dexamethasone or acetic acid delivered via iontophoresis can be used to provide short-term (2-4 weeks) pain relief and improved function.
• There is strong evidence to support the use of prefaabricated or custom foot orthoses to provide short term (3 months) pain relief and improved function. But there is currently no evidence to support the use of
those for long term (1 year) management or function improvement.
49
Nominate the techniques weakly supported by science to help in plantar heel pain.
* There is minimal evidence to support the use of manual therapy and nerve mobilizations to provide short-term (1-3 months) pain relief and improved function; includes talocrural, subtalar, TMT, STM, and neural mobilizations.
* There is weak evidence to support calcaneal or low dye taping to provide short-term (7-10 days) pain relief.
50
Refer the Return to Sport Criteria in cases of plantar fasciitis.
* Increased activity should be avoided until the athlete can walk a full day without any pain
* Progress participation as tolerated with continued stretching throughout day.
51
Give exemples of exercices to hallux rigidus.
* Isometrics followed by isotonics
* Picking up marbles with toes
* Seated heel raises.
52
What is the degree of evidence that support therapeutic laser in Achilles tendinopathy? What are the parameters?
There is moderate evidence in support of laser therapy to decrease pain, tenderness, morning stiffness, active DF ROM, and improve function in patients with Achilles tendinopathy.
• LLLT + eccentric exercise superior to eccentric exercise alone (Stergioulas et al).
• 6 points along the painful achilles tendon at 820nm with an energy of 0.9J per point.
53
Identify the therapeutic laser mechanisms of action.
* Anti-inflammatory effect
* Stabilization of lipid peroxidation
* Analgesic effect
* Reparation process stimulation
* Immune response stimulation
* Reflexogenic effect.
54
Discuss the possible mechanisms of therapeutic laser for pain relief.
• No direct stimulation of sensory/motor afferent fibres -
not Segmental inhibition
• Direct effects on nerve conduction
• Suppression of small diameter nociceptors. Neuropathic pain-local release of neurotransmitters such as serotonin.
• Evidence for opioids? Increased release of endorphins in rat; other studies no evidence of peripheral opioid increase.
• Main effects at cellular level
• Alterations in blood flow
• Anti-inflammatory effects** (affects a range of peripheral inflammatory mediators)
• Debate whether difference between acupuncture and laser.
55
LLLT can potentially be effective in treating tendinopathy when recommended dosages are used. Match each of the parameters with his correspondent tendinopathy:
A) 904 nm 1064 nm; 60 mW/cm2; 1,8-3,5 J/cm2.
B) 820 nm 904 nm; 320 mW/cm2; 19,2 J/cm2.
C) 820 nm 904 nm; 20-60 mW/cm2; 1,8-3,6 J/cm2
D) 830 nm; 32 mW/cm2; 4 J/cm2.
A) Epicondylitis;
B) Rotator cuff;
C) Achilles;
D) Wrist.
56
Summarise the evidence of interventions to Achilles tendinopathy.
* There is moderate evidence in support of iontophoresis with dexamethasone to decrease pain and improve function
* There is weak evidence in support of stretching or foot orthoses to reduce pain in patients with Achilles tendinopathy
* Manual therapy, including soft tissue mobilization, and taping may reduce pain and improve function but are based on expert opinion alone
* Contradictory evidence exists for the use of heel lifts in patients with Achilles tendinopathy
* There is weak evidence that night splints are NOT beneficial in reducing pain when compared to eccentric exercise for patients with Achilles tendinopathy.
57
In which cases it's recommended to use night splints? How many time?
* There is moderate evidence that night splints should be considered as an intervention for patients with symptoms greater than 6 months in duration.
* Desired length of time for wearing the night splint is 1-3 months.
58
What is the general treatment of proximal 5th metatarsal?
* Prolonged healing times
* Significant risk of refracture
* Non Weight Bearing in short-leg cast x 6-8 weeks followed by 6 weeks protected weight-bearing
* Trend toward primary surgical fixation (intramedullary screw fixation)
* Postoperative care typically consists of early ROM and weight bearing as tolerated
* Return to sport usually 6-8 weeks post-op.
59
How it's handled a tibial stress fracture?
* Non-critical
* Rest until pain resolved
* Return to full sport activity within 8-12 weeks.
60
What can be the conservative and surgical treatment for compartment syndrome?
```
Conservative:
• Relative rest
• Anti-inflammatories
• Stretching/strengthening of involved muscles
• Orthotics.
```
Surgical:
• Fasciotomy.
61
In case of fasciotomy to a compartment syndrome, describe a protocol that can be utilised.
1) ROM exercices of knee and ankle in the immediate postoperative period.
2) 3 to 5 of limited WB (weight bearing) on crutches, then full WB as tolerated.
3) Once wounds are healed, strenghtening program, cycling and swimming.
4) Gradual return to light jogging at about 4 to 6 weeks after surgery.
5) Full sports participation at 8 weeks (one compartment released) and 12 weeks (multiple compartments).
6) The patient should be pain-free with 90% of strenght regained prior to full sports participation.
62
How do we treat MTSS (medial tibial stress syndrome)?
* Relative rest
* Ice, compression, elevation
* Avoidance of hill running or running on uneven surfaces
* Orthotics to minimize rearfoot valgus and correct excessive pronation
* NSAIDs
* Gastroc stretching/strengthening.
63
How we manage grade I turf toe?
* Grade I - Attenuation of plantar structures; Localized swelling; Minimal ecchymosis.
* Treatment: Symptomatic
* Return as tolerated.
64
Describe the grade II of turf toe and RTP.
• Grade II - Partial tear of plantar structures; Moderate swelling; Restricted motion due to pain.
• Treatment: Walking boot; Crutches as needed.
• RTP: Up to 2 weeks; May need taping on
return to play.
65
What is the possible treatment and RTP of grade III turf toe?
* Grade III - Complete disruption of plantar structures; Significant swelling/ecchymosis; Hallux flexion weakness; Frank Instability of hallux MTP
* Treatment: Long-term immobilization in boot or cast OR Surgical reconstruction
* RTP: 10 to 16 weeks depending on sport and position Likely to need taping on return to play.
66
In case of turf toe mechanism, what are the indications for Surgical Repair?
* Large capsular avulsion with unstable MTP joint
* Diastasis of bipartite sesamoid
* Diastasis of sesamoid fracture
* Retraction of sesamoid
* Traumatic hallux valgus deformity
* Vertical instability (positive Lachman test result)
* Loose body in MTP joint
* Chondral injury in MTP joint
* Failed conservative treatment.
67
What are the intervention options to hallux rigidus?
* Foot orthoses
* Full length rigid insoles to prevent dorsiflexion
* Anterior rocker bottom shoe
* NSAIDs
* If conservative treatment fails, joint arthrodesis is most successful surgical outcome with better functional outcomes and fewer revision rates.
68
How to perform sesamoid mobilization with movement?
The therapist places one thumb on the proximal aspect of the sesamoid and applies a proximal to distal force causing the sesamoid to reach the end range of available motion. You can also ask the patient to perform concurrent MTP extension.
69
How to instruct balance training (single leg stance)?
1-legged standing on the injured limb, with arms abducted and eyes open for 30 seconds. This exercise can be progressed from arms abducted to arms crossed; eyes open to eyes closed; and more dynamic balance including standing on balance/wobble board with eyes open/eyes closed, throwing and catching a ball.
70
Explain how we apply low dye taping.
The patient begins in supine. Wrap a full strip from the 5th metatarsal head to the 1st MTP as an anchor strip. Using several strips, wrap from the 5th metatarsal head diagonally across the bottom of the foot, wrapping around the calcaneus and back up alongside the foot to the same side you started on. Alternate your starting side from the metatarsal heads overlapping half of the previous strip. Repeat until the tape cover the 5th through 1st metatarsal heads. Next, add full width strips across the arch of the foot pulling from lateral to medial pulling the arch up. Overlaps each strip by half and avoid wrinkles in the tape on weightbearing surfaces. Last, complete by adding a cover strip around the edge of the foot starting at the 5th metatarsal head, wrapping around the calcaneus to the 1st metatarsal head.
71
When performing an anterior to posterior glide of the talocrural joint, you are focused on improving which motion?
An anterior to posterior glide focuses on a posterior glide of the talus on a stable mortise promoting ankle dorsiflexion.
72
In general, manual therapy has strong evidence in support of its use for long term benefits in patients with ankle sprains. True or false?
False. Manual therapy has moderate evidence to support its use in the short term with exercise showing greater benefits long term.
73
```
The effectiveness of therapeutic laser in treating achilles tendinopathy is based on which of the following parameters?
• Wavelength between 820 and 904 nm
• Power density between 20-60 mW/cm2
• Dose of 1.8-3.6 J/cm2
• All of the above
```
All of the above. Effectiveness of therapeutic laser is dependent upon specific ranges of power density, dose, and wavelength.
74
What we can't never forget when we treat a low extremity dysfunction in general?
* Don’t forget the gluts!
* Hip extension/abductor weakness present in those with chronic ankle sprains
* Altered hip muscle recruitment patterns following a sprained ankle
* Local sensory changes and altered hip muscle function following severe ankle sprain.
75
What is the risk of recurrent sprain with and without balance training?
Balance training relative risk reduction of 54%:
– Recurrent sprain within 8 months = 54% without balance training
– Recurrent sprain within 8 months = 25% with balance training.
Supervised rehab relative risk reduction of 79%:
– Recurrent sprain within 1 year = 29% without rehab
– Recurrent sprain within 1 year = 6% with rehab.
76
What is the effect of six weeks of dura disc and mini trampoline balance training on postural sway in athletes with functional ankle instability?
• Balance training with use of a minitrampoline or dura disc x 6 weeks showed significant decreased in postural sway following lateral ankle sprain.
(Pretest sway = 56.8 +/- 20.5mm; posttest 33.3 +/- 8.5mm).
77
Patients with CAI demonstrate deficits in postural control and SEBT (star excursion balance test) reach tasks compared to the uninvolved limb. How a strenght and balance training rehab can help?
• Following rehab consisting of both strength and balance training, patients demonstrate greater SEBT reach improvements on the involved limb than the control and greater improvements in FADI (functional ankle disability index) scores.
78
Exemplify exercices to neuromuscular control and functional tasks.
Neuromuscular control:
• Single-limb stance
• Single-limb stance ball toss
• Single-limb stance while kicking against resistance in 4 directions
• Step-downs with single limb in 4 directions.
Functional tasks:
• Box hop/quardrant hop
• Carioca
• Figure of eight.
79
What about local strengh between ankle evertors and invertors?
• When ankle evertor strength exceeds invertor strength, person at increased risk for lateral ankle sprain – Eccentric control of invertors may limit lateral translation of trunk over stance leg.
80
```
Patients suffering from chronic ankle instability may show additional deficits away from the ankle in which of the following areas?
• Lumbar spine
• Hip
• Shoulder
• Cervical spine
```
Hip. Studies have shown that in patients with chronic ankle instability, hip extension and abductor weakness is present as well as altered hip muscle recruitment patterns.
81
A supervised rehabilitation following an ankle sprain has the ability to reduce risk of a recurrent sprain by 79% within 1 year. True or false?
True. Recurrent sprains suffered within 1 year were 29% in those without rehab as compared to only 6% in those with rehabilitation leading to a risk reduction of 79%.
82
Refer some benefits of regular general exercise.
In older adults, regular exercise provides numerous health benefits that include improvements in blood pressure, coronary artery disease, diabetes, lipid profile, osteoarthritis, osteoporosis, mood, neurocognitive function, and overall morbidity and mortality.
83
What's the deal with obesity and regional injuries?
* Being overweight or obese significantly increases the chance of having tendinitis in general.
* There is also an increased likelihood of plantar fasciitis amongst obese individuals.
84
Refer some global interventions that can help to prevent stress fractures.
* Military studies have demonstrated an increased risk of stress fractures among recruits with lower levels of activity before military training; the same has been found in runners and athletes with more stress fractures occurring in freshmen(67%) as compared to seniors (7%)
* Increased levels of calcium have demonstrated a fracture risk reduction of 62% for each additional cup of skim milk consumed per day; high levels of calcium (1500-2000mg) may be protective against risk fractures
* Frequent footwear change (every 6 months or 300-500 miles) is essential and can independently decrease the risk of stress fractures.
85
What is the relationship between core stability and lower extremity function and injury?
* Current evidence suggests that decreased core stability may predispose to injury and that appropriate training my reduce lower extremity injury
* Balance board and stability disc exercises, performed in conjunction with plyometric exercises are recommended to improve proprioceptive and reactive capabilities, which may reduce the likelihood of lower extremity injuries.
86
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Which of the following global issues places individuals at increased risk for injury?
• Age
• Obesity
• Old shoes
• All of the above
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All of the above.
• The degenerative aging process places elderly individuals at risk in the case of exertional type injuries.
• Being overweight or obese significantly increases the chances of having tendinitis in general and also increases the likelihood of plantar fasciitis.
• Frequent footwear change can increase risk of stress fracture.
87
Core stability training is an important component of reducing the risk of lower extremity injury. True or false?
True. Current evidence suggests that decreased core stability may predispose to injury and that appropriate training may reduce lower extremity injury.
