Lower Quarter Exam #3

What is the talocrural joint?

tibia/fibula approximating with the talus

What motion does the mortise joint provide stability for?

dorsiflexion

Where is the talus wider?

anteriorly

Where does relative stability decrease?

plantarflexion

What composes the lateral collateral ligament complex?

anterior talofibular ligament, calcaneofibular, and posterior talofibular ligament

What is the ATFL's primary role?

resists anterior taler translation and inversion in PF

What is the CFL's primary role?

resists inversion in neutral/DF

What is the PTFL's primary role?

stabilizes against posterior taler displacement

Which lateral ankle ligament is the most commonly injured?

ATFL

Which lateral ankle ligament is often involved with more severe sprains?

CFL

Which lateral ankle ligament is rarely seen injured in isolation?

PTFL

What structures beyond ligaments help with stabilization of the lateral ankle?

fibularis musculature

What does the fibularis musculature do?

provides active resistance to excessive inversion, frontal plant ankle stability, and importance in rapid perturbations/landing tasks

How is ankle stability more than strength?

allows for sensory input to trigger the CNS making a motor response to the perturbation

Why does sensory input to the ankle matter to us?

after an injury, sensorimotor control, balance and movement strategy may change until swelling resolves

What are the static stabilizers of the medial ankle?

deltoid ligament complex

What does the deltoid ligament complex restrain?

excessive eversion and external rotation

What are the dynamic stabilizers of the medial ankle?

tibialis posterior, flexor hallucis longus and flexor digitorum longus

What is the classic mechanism of a lateral ankle sprain?

plantarflexion and inversion

What history will be involved in a lateral ankle sprain?

MOI, audible pop, immediate swelling, not able to continue activity, and prior ankle sprains

What will we observe with a lateral ankle sprain?

swelling, ecchymosis, deformity, and WB tolerance

What should we palpate if suspect of a lateral ankle sprain?

ATFL, CFL, PTFL, deltoid, base of 5th metatarsal, navicular and distal tibia/fibula

What are the Ottawa foot and ankle rules?

if suspect of fx, should palpate the following: posterior distal edge of fibula, base of 5th metatarsal, posterior distal edge of tibia, and navicular

What else should we look at if suspecting fracture?

if the patient can WB on the foot/ankle at all, if they can't send for imaging

What does the anterior drawer test for?

testing for increased anterior talar translation, suggests ATFL injury

What does the talar tilt test for?

increased inversion laxity, suggests CFL injury; increased eversion laxity, suggests deltoid injury

What does the posterior drawer test for?

suggests severe lateral ligament injury of ankle dislocation hx, PTFL

What does the external rotation stress test for?

pain over distal tibiofibular syndesmosis indicating possible high ankle sprain

What does the squeeze test for?

pain at syndesmosis with tibia/fibula compression suggests syndesmotic injury (high ankle sprain)

What should we suspect if we have pain at the area of pressure from hands during squeeze test?

tibia/fibula fx

What is a Jones fracture?

injury at the base of the 5th metatarsal (peroneus brevis insertion), can be avulsion of peroneus brevis or normal fx

How do we differentiate Jones fracture?

palpation of 5th metatarsal and MMT of peroneus brevis induces pain

During a lateral malleolus fracture, what might cause an increased risk of syndesmotic disruption and ankle instability?

more proximal fibular fracture

How do we differentially diagnose malleolar fractures?

Ottawa ankle rules, inability to walk, and swelling

What is peroneal subluxation?

subluxation of the peroneal tendon out of fibular groove

Where is the pain located in peroneal subluxation?

behind the lateral malleolus to the base of the 5th metatarsal

What else is holding the peroneal tendons in place that may be leading to peroneal subluxation?

peroneal retinaculum

How do we test for peroneal subluxation?

resisted PF, look for subluxation of the tendon

Where is the most common location of osteochondral lesions of talus?

anterolateral portion

What MOI leads to anterolateral osteochondral lesion of talus?

PF and inversion

How do we differentially diagnose an osteochondral lesion of talus?

DELAYED SWELLING, hx of chronic ankle instability, tender to palpation, pain with DF and inversion, and c/o pain along medial joint line with compression

What are the treatment options for osteochondral lesions of talus?

same as osteochondral lesion of knee

What is a syndesmotic injury?

aka high ankle sprain, which is a stretch or tear of the syndesmosis and other structures

How do we differentially diagnose a high ankle sprain?

pain during WB, pain during external rotation + DF of talus, and pain during squeeze of tibia and fibula together

What is the typical MOI of a high ankle sprain?

planted foot with DF and external rotation

What is a syndesmotic stress view on x-ray show us?

increased joint space between tibia and fibula (>5mm)

What are the treatment goals for lateral ankle sprain?

protect healing tissues, optimally load, restore pain-free ROM, normalize gait and WB, restore strength/power, re-establish sensorimotor control, and RTS safely

What are the goals of early phase lateral ankle sprain treatment?

control pain/swelling, restore ROM, normalize gait and maintain strength proximally

What interventions are used in early phase rehab for lateral ankle sprain?

brace/tape as indicated, early WBAT, AROM, DF mobilization, isometrics, and hip/core strengthening

What do we want to avoid during early phase rehab for lateral ankle sprain?

aggressive inversion stretching and prolonged immobilization

What can we do for progressive strengthening for lateral ankle sprain?

band strengthening, heel raises, step-ups, lunges, and squats

What can we do for neuromuscular training for lateral ankle sprain?

single-leg balance, perturbations, Y-balance progression, blazepods, dual-task balance, stroboscopic glasses, and VR perturbation

What is the objective return-to-sport criteria for lateral ankle sprain?

minimal pain/effusion, full ROM, strength >90-95%, Y-balance within acceptable asymmetry, hop testing >90%, sport-specific agility, and athlete confidence

What are the three principles we should follow for lateral ankle sprain?

1) early loading > prolonged immobilization (except for severe injuries requiring protection)

2) balance and neuromuscular training reduce recurrent sprains

3) patients recover function before neuromuscular deficits resolve, contributing to chronic ankle instability

What are the risk factors for chronic ankle instability?

previous sprain, incomplete rehabilitation, sensorimotor deficits, poor balance, reduced DF, and early RTS

What is the primary indication for arthroscopic debridement?

impingement, synovitis, loose bodies

What is the primary goal of arthroscopic debridement?

remove painful intra-articular pathology

What is the primary indication for a microfracture/cartilage restoration?

osteochondral lesion of the talus

What is the primary goal of microfracture/cartilage restoration?

stimulate cartilage repair or restore articular cartilage

What is the primary indication for peroneal tendon repair (tubularization/weave)?

longitudinal tendon tear

What is the primary goal of peroneal tendon repair (tubularization/weave)?

restore tendon integrity and function

What is the primary indication for superior peroneal retinaculum repair?

recurrent peroneal tendon subluxation/dislocation

What is the primary goal of superior peroneal retinaculum repair?

stabilize the peroneal tendons

What is the primary indication for a modified Brostrom-Gould Repair?

chronic lateral ankle instability

What is the primary goal of modified Brostrom-Gould repair?

restore ATFL/CFL stability

What is the primary indication of a tendon reconstruction?

failed Brostrom or poor tissue quality

What is the primary goal of tendon reconstruction?

reconstruct lateral ligament complex

What is the primary indication for syndesmotic fixation?

unstable syndesmotic injury

What is the primary goal of syndesmotic fixation?

restore distal tibiofibular stability

What is a syndesmotic screw fixation?

putting a screw through the fibula into the tibia to stabilize the syndesmotic joint

What are some characteristics of a syndesmotic screw fixation?

more rigid motion, more conservative WB, gain ROM slower, and longer period before running and RTS

What is a suture button syndesmotic fixation?

putting a string through the fibula into the tibia to stabilize the syndesmotic joint and allow for more ROM with restriction

What are some characteristics of a suture button (tightrope) syndesmotic fixation?

dynamic stabilizer, earlier WB, earlier ROM, and shorter time frame before running and RTS

After syndesmotic fixation, what is one thing we want to avoid?

aggressive DF early on

What is a Maisonneuve fracture?

syndesmotic injury along with medial malleolar fx OR proximal fibula fx

What is the MOI of Maisonneuve fracture?

forceful external rotation of foot and fibula internal rotation

What is a Brostrum repair?

repairing the natural ligaments

What is the modified Brostrum-Gould repair?

repairing the natural ligaments and the extensor retinaculum

Who are good candidates for a total ankle arthroplasty?

end-stage tibiotalar OA, failed conservative tx, age >50-60, lower demand on joint, good alignment and adequate bone stock, and correctable deformity

What are contraindications to total ankle arthroplasty?

active infection, neuropathy/charcot arthropathy, severe vascular disease, poor soft tissue envelope, severe uncorrectable deformity

What is an ankle arthrodesis?

fusing the joint together

What should we focus on in examination after total ankle arthroplasty?

incision healing, effusion, DF/PF ROM, Achilles flexibility, calf strength, single-leg balance, stair negotiation, and gait efficiency

What should our exercise progression look like for total ankle arthroplasty?

ROM, isometrics, theraband, heel raises, balance progression, functional stepping, and walking progression

What activities do well with a total ankle arthroplasty?

walking, hiking, gold, cycling, and swimming

What are risk factors for plantar fasciopathy?

sudden increase in WB activity, running/prolonged standing, limited ankle DF, higher BMI, age 40-60, occupations requiring prolonged standing, and improper footwear

What subjective information is indicative of plantar fasciopathy?

pain at medial calcaneal tubercle, worst with first steps in the morning, pain after prolonged sitting, improves somewhat with activity, and returns with prolonged WB

What objective information is indicative of plantar fasciopathy?

tender medial calcaneal tubercle, windlass test, limited DF, point palpation at medial calcaneal tubercle, tight gastrocnemius, great toe mobility and pain with prolonged single-leg heel raise

What are the main functions of the foot?

shock absorber, rigid lever, and mobile adapter

What strong treatment evidence do we have for plantar fasciopathy?

manual therapy (talocrural, subtalar, and soft tissue), stretching (gastroc, soleus, and plantar fascia), and arch taping

What moderate treatment evidence do we have for plantar fasciopathy?

progressive strengthening, NM training, and foot intrinsic strengthening

What are some adjunct treatments for plantar fasciopathy?

night splints/orthoses (short-term) and shockwave (chronic)

What is tibialis posterior tendinopathy?

overuse of posterior tibial tendons that leads to pain and poor muscle use quality

What is tibialis posterior insufficiency?

difficulty or inability to use tibialis posterior tendons, progression of tendinopathy

What is the tibialis posterior responsible for?

turning foot into rigid lever (locks out subtalar joint)

What leads to failure of the posterior tibial tendon?

excessive pronation and limited talocrural motion

What things would be difficult with posterior tibial tendon insufficiency?

difficulty or inability to perform a unilateral heel raise

How do we differentially diagnose tibialis posterior tendinopathy/insufficiency?

pain towards the arch but not as focal as plantar fascia (along the tendon insertion), possible collapsing foot deformity, painful to MMT, not painful to windlass mechanism, painful or unable to perform heel raise, typically no warm-up effect

What is tenosynovitis?

pain with performance of unilateral heel raise

What is tarsal tunnel syndrome?

compression of the tibial nerve or one of its branches leading to pain, N+T in medial/lateral plantar nerve or both

What testing is used for tarsal tunnel syndrome?

Tinnel's in tarsal tunnel, sensory testing from knee down, and toe flexion MMT (will be weakened