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PODMED3 > wk 11- achilles/ ankle/RF pain > Flashcards

wk 11- achilles/ ankle/RF pain Flashcards

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1
Q

types of achilles pain

A

midportion

insertional tendinopathy

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2
Q

achilles rupture

A

explosive activity with a loud crack and initial feeling of being kicked

more common in males

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3
Q

assessments for achilles rupture

A

calf squeeze test

simmonds test

thompsons test

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4
Q

treatment for achilles rupture

A
  1. referral to orthopeadic surgery for repair
  2. conservative rehab
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5
Q

what tendon is medial to the achilles

A

plantaris tendon

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6
Q

stages of achilles tendinopathy

A

stage 1- reactive tendinopathy: short term adaption to overload. non inflammatory proliferative response, tendon thickens

this can reverse back to normal if given time to rest between loading and overload is reduced

stage 2- tendon dysrepair
tendon attempts to heal with matrix breakdown (increase number of cells and vascularity on ultrasound)

stage 3- degenerative tendinopathy
progression of matrix disorganisation/breakdown, cell changes and neovascularisaton

if load not reduced, rupture as the tendon is structurally unable to transmit tensile loads

reactive on degenerative:
structurally normal portion of tendon may go in and out of a reactive response

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7
Q

clinical features of mid portion achilles tendinopathy

A

pain/stiffness 2-6cm above posterior calc

burning pain

pain increased with activity and relieved with rest

thickening palpated

negative calf squeeze test

postitive royal london hospital test - pain absent on max dorsiflexion

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8
Q

what is there little evidence on correlation with achilles tendinopathy

A

STJ pronation

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9
Q

intrinsic and extrinsic risk factors for achilles tendinopathy

A

int:
1. weak plantarflexion strength
2.increased/reduced dirsflexion ROM
3. reduced knee flexor strength
4. poor tendon structure

ext:
1. increased tendon loading with activities
2. FW
3. surface

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10
Q

imaging for achilles tendinopathy and what to look for

A
  1. US
    -tendon thickening
    -neovessels
    -hypoechogenic
    -disorder fibres
    -tissue gaps
    -fluid
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11
Q

management of achilles tendinopathy

A
  1. alfredsons protocol
    3x15 reps twice a day, every day for 12 weeks

knee straight and bent knee lowering on injured leg

can progress with weight

if theres improvement continue for 6-12 months

  1. 4 stage achilles rehab program
    - isometric calf raise 45sec, 4-5reps with 2 mins rest. completed 2-3 times a day
    -isotonic calf raise, slow eccentric. twice a week
    -energy storage, slow skipping 3 times a week
    -energy storage and release
  2. if theres no improvement
    -modify load/activtiy
    -consider other modalities like electrotherapy,massage, GTN patch
    -surgery last resort
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12
Q

what can plantaris do to achilles

A

compresses achilles
or ensheafed in tendon

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13
Q

how to know if theres plantaris involvement in achilles pain

A

-pain more medial ad proximal
-pain aggrevated by loading in dorsiflexion

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14
Q

what type of tendinopathy is most common

A

mid portion

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15
Q

how does insertional achilles tendinopathy occur

A

excessive tendon load with compression against the calc

excessive dorsflexion with high tensile loads

increased compression when pushing against resistance

running uphill

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16
Q

clinical features of insertional achilles tendinopathy

A

palaption of posterior calc causes pain

there may be pain on dorsiflexion

swelling

royal london test

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17
Q

management of insertional achilles tendinopathy

A
  1. deload
    2.avoid barefoot/ heel raises
    3.staged loading rehab (alfred or 4 stage) avoiding dorsiflexion (not on step)
  2. dont over stretch
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18
Q

bone pathology of the ankle/RF

A

talar dome lesion

calcaneal apophysitis

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19
Q

soft tissue pathology of ankle and RF

A

post tib tendinopthy
post tib dsfunction
peroneal tendinopthy
tib ant tendinopathy
FHL tendinopthy
achilles tendinopathy
retrocalcaneal bursitis

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20
Q

joint pathology of ankle

A

ankle impingement anteiror/posteiror

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21
Q

neural/vascular pathology of ankle

A

tarsal tunnel syndrome

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22
Q

talar dome lesion is what

A

osteochondritis dissecans of the talar dome

(subchondraol bone and articular cartilage separate from underlying bone)

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23
Q

how does talar dome lesions occur

A

trauma/injury (inversion ankle sprain that doesnt improve with conservative treatment)
vascular failure
genetic predisposition

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24
Q

posterior medial talar dome lesions occur by

A

foot plantarflexed during inversion

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25
anterolateral talar lesion occurs when
foot is dorsiflexed
26
clinical features of talar dome lesion
pain around anterior ankle when plantarflexed swelling stiffness/ reduced ROM popping, clocking, locking (loose body)
27
management of talar dome lesion
1. immobilise in NWB cast 3-4weeks 2. then immobilise in CAM walker 6-10 weeks 3. surgery
28
what is post tib tendon dysfunction
loss of dynamic and static support of MLA, hindfoot, ankle (not just post tib) dynamic: -plantar aponeurosis -post tib tendon -plantar intrinsic muscles static: -spring lig -superficial deltoid lig -long and short plantar lig -plantar aponeurosis flat foot deformity
29
risk factors of PT dysfunction
-40years and more -woman -obese -hypertension -diabetes -trauma or surgery to medial aspect of foot
30
patho of PTTD
- existing flatfoot - increased gliding resistance of PTT -everted hindfoot unlocks midtarsal joint during midstance/terminal and heel rise -increased strain on supportive ligamnents and post tib -attenuation and rupture of PTT -rupture of spring lig, deltoid and plantar ligs
31
soemone with long standing flexible flat foot is prediosposed to
PTTD
32
stages of PTTD
1- tensosynovitis (flexible) 2- atteuation or rupture (flexible, may not be able to heel raise) 3- complete rupture (rigid) 4- valgus talo crural joint (rigid)
33
assessing PTTD
-double and single leg raises look for heel heights and supination if unable to perform heel raise it indicates stage 2 PTTD -jacks test- windlass mechanism -assess flexibility of rearfoot inversion and eversion if rigid then its a sign of stage 3/4 PTTD -assess NWB muscle strength -supination lag: getting patient to plantarflexed and bring soles together (less movement in PTTD)
34
treatment for PTTD depends on
stage
35
stage 1 PTTD management
1. reduce inflammation 2. immobilise (CAM walker, bracing, taping low dye 3. footwear modifications (medial wedge, flares) 4. orthoses
36
stage 2 PTTD management
1. immobilise (CAM walker 1-6 weeks 2. custom foot orthoses - kirby skive, inverted poor 3. custom hinge AFO (richie brace) 4. footwear modifications 5. rehab program
37
stage 3 PTTD management
- if no severe DJD (degenerative joint?) in ankle and hindfoot then restricted hinge AFO (richie brace) -if there is Gauntlet with flexible AFO shell
38
stage 4 PTTD mangement
gauntlet with rigid AFO shell
39
what does a richie brace do
treats PTTD foot drop chronic ankle instability types standard dynamic gauntlet
40
FHL tendinopathy caused by
repetitively going onto toes when plantarflexion is required wearing shoes too big walking down hill (gripping of toes) associated with posterior impingmenet syndrome enlargement of os trignonum compresses FHL FHL runs between sesamoids plantar 1st MTPj
41
clinical features of FHL tendinopathy
-pain with toe off or forefoot loading -pain when landing -aggrevated with resisted flexion or passive stretch into dorsiflexion
42
management of FHL tendinopthy
1. rest 2. FHL isometric/isotonic strength 3. soft itssue therapy 4. orthotics 5. taping
43
peroneal tendinopathy
most common lateral ankle pain causes 1. inversion injury (overstretch of tendon) 2. overuse due to RF eversion/ lat deviated STJ 3.tight ankle plantar flexors causing an increase load on lateral muscles 4. overuse due to dancing, jumping, soft footwear
44
types of peroneal tendinopathy
1. posterior to lateral malleoli (most common) 2. peroneal trochlea 3. plantar surface of cuboid
45
clinical features of peroneal tendinopathy
lateral ankle or lateral heel pain worsens with activity tenderness along peroneal pain on passive inversion and resisted eversion tight calf muscles
46
management of peroneal tendinopathy
1. immobilise/rest (CAM walker) 2. soft tissue therapy/manual therapy 3. lateral heel wedge 4. eccentric strength with eversion
47
tib ant tendinopathy
overuse of tib ant due to 1. restriction in ROM 2. stiffness in ankle 3. walking/running downhill
48
clinical features of tib ant tendinopathy
-pain, swelling, stiffness in anterior ankle -occasional crepitus -aggrevated by walking running up hills or stairs -tenderness along tendon -resist dorsiflexion and eccentric inversion gives pain
49
management of tib ant tendinopathy
1 rest 2. soft tissue theray, amnual therapy 3. address cause 4. eccentric strengthening
50
what is ant ankle impingment
common in football and ballet dancers soft tissue or bone compresses between the talus and tibia during dorsiflexion
51
clinical features of ant ankle impingement
vague discomfortable at front of ankle which becomes sharper and more localised with dorsiflexion lunge test is painful and typically shoes limited range
52
management of ant ankle impingement
1. heel raise 2. rest- limit dorsiflexion 3. NSAIDs 4. manual therapy 5. taping 6. arthroscopic removal if exostosis
53
what is posterior ankle impingement
soft tissue or bone compresses between tibia and superior aspect of calc common in footballer, ballet dancers can occur in enlarge posterior tubercles or ostrignonum
54
sinus tarsi syndrome
interosseous ligaments, synovial membrane, blood vessels, fat and connective tissue located in this area that can be compressed and cause synovitis/inflammation
55
clinical features of sinus tarsi syndrome
vague, pain near anterior/lateral mall pain worse in morning and improves with activities pain worse on uneven surfaces pain on passive eversion and inversion of STJ tenderness on palpation and over ATFL
56
management of sinus tarsi syndrome
1. rest 2. NSAIDs, ice 3. movilisation of STJ 4. CSI in sinus tarsi 5. address biomechanics 6. proprioceptive and strength trainign
57
calc stress fracture clinical features
-intense diffuse heel pain along medial and lateral aspect of posterior calc -pain worse wb and activity -persistent night pain -positive squeeze test or pain on direct compression
58
managament of stress fracture of calc
1. immobilise (CAm walker, soft cast) 4-8weeks 2. rehab strength program 3. heel cushions 4. assess biomechanics, BMD, training load, footwear, etc
59
what is plantar heel pain (plantar fasciopathy)
overuse condition of the plantar fascia at its attachment to the calc
60
risk factors for plantar fasciopathy
1. running (cavus foot and hindfoot in runners) 2. BMI 3. standing time/walking on hard surfaces 4. impactful daily activities 5. high arch 6. reduced ankle dorsflexion 7. hammy tightness (8x more likely to have heel pain) 8.leg length difference
61
patho of plantar fasciopathy
1. reduced neuromuscular activity in the muscles in the foot leading to increased loads of the fascia or 2. mechanical deficiency in the fascia which makes it unable to take normal levels of stress
62
clinical features of plantar fasciopathy
- heel pain after increase in WB actvitiy -pain worse in morning when getting out of bed -pain on palpation of proximal insertion of fascia -positive windlass test -negative tarsal tunnel test -abnormal FPI score -BMI
63
plantar medial heel pain
most noticeable with initial steps after inactvitiy and worse following prolonged wb
64
ddx for heel pain
spondylarthritis fat pad atrophy plantar fibroma baxters nerve entrapment a fascial tear heel spur calc stress fracture
65
what is a common radiographic finding in heel pain
calc spurs
66
what is the thickness looking for in US for fascia
>4mm
67
management of plantar heel pain (1st)
3 teirs 1st: -padding and strapping, low dye -stretching fascia and calf -footwear advice with cushioning and support -NAIDS -arch support -prefab with heel cup, pad
68
2nd tier PHP
AFTER 6 WEEKS 2nd tier: - corticosteroid injection -dry needling for lower limb muscles -custom orthotics -immobilisation -high load strength (heel raises with towel under toes)
69
3rd tier
after 6 months 3rd tier -night splint / strassburg sock -shockwave therapy -surgery plantar fasciomoty fasciectomy
70
fat pad syndrome
damage, atrophy, inflammation, contusion common in elderly (50yrs) and diabetes
71
clinical features of fat pad syndrome
deep, non radiating pain WB portion of calc tubercle barefoot makes worse pain on palpation of central plantar aspect of heel
72
management of fat pad syndrome
1. NSAIDs/paracetamol 2. footwear modifications to reduce plantar pressure (aperture) 3. silicine heel cup 4. reduce WB activities 5. footwear advice (cushioning) 6. taping- heel lock, x arch taping
73
what is piezogenic papules
minor herniation of adipose tissue that surrounds the calc may be associated with ehlers dnalos sydnrome common in long standing, marathon runners, weight lifters
74
managament of piezogenic papules
1. corticosteriod injection 2. deoxycholic acid injection (breaks down cells in fatty tissue) 3. reduce standing 4. compression stockings 5. soft heel cups
75
what is baxters nerve entrapment
entrapement of the 1st branch of lateral nerve which innervates abductor digiti minimi muscle can be entrapment between deep fascia of adductor hallicus and quadratus plantae or anterior calc near the medial calc tubercle
76
clinical features of baxters nerve
-medial/plantar heel pain -worse at night and is constant -tenderness over medial aspect of plantar heel -inability to abduct 5th toe -no sensory deficits
77
management of baxters nerve
1. NSAIDS 2. shock absorbing innersoles 3. MLA support 4. steroid injections if no change after 6 months 5. surgery
78
tarsal tunnel syndrome
tibial nerve compression in the tunnel uncommon but occurs from fracture or dislocation of the medial ankle area
79
clinical features of tarsal tunnel
-aching, burning, numbness -radiating pain in calf -worse at night and standing -prominent tinel's sign -dorsiflexion/eversion test which stresses tibial nerve
80
management of tarsal tunnel
1. NSAIDs 2. footwear modifications 3. CSI 4. surgery
81
what is sondyloarthrophy?

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