DPTD 852 - foot/ankle peds & referred pathology

sever disease pathology

overuse or repetitive stress of the Achilles on the open epiphyseal plate at the calcaneus due to…

• increased tendon stress due to rapid growth spurts

• obesity

• mechanical disruption secondary to microtrauma

• strain caused by striking the heel in children with arch differences

epiphyseal plate at calcaneus closes at ___ yrs old

13-15

sever disease examination findings

• tenderness & swelling at Achilles insertion, may have pain lower on heel

• s/s gastroc/soleus

• decreased ankle DF

sever disease PT management

• activity modification

• education (usually settle in 6-12 months, can last up to 2 years)

• heel lift in shoes

• stretch & strengthen gastroc/soleus

talipes equinovarus management

• splinting and/or serial casting

• Surgery indicated if casting fails to correct

type I Salter-Harris fracture

separation of epiphysis from metaphysis

type II Salter-Harris fracture

fx line runs along physis through metaphysis - epiphysis is not involved

• involved growth plate & joint surface → higher complication rate

• most common type

most common location for Salter-Harris fracture for foot/ankle

distal tibia & distal fibula

Salter-Harris fracture symptoms

• inability to WB on involved side

• localized joint pain

• swelling, tenderness at the physis

Salter-Harris fracture PT management

• occurs after casting/surgery

• ROM not often limited & quickly regained

• focus on improving strength & mobility

• gait, balance, proprioceptive training

acute compartment syndrome pathology

typically occurs after trauma to the leg

chronic compartment syndrome pathology

caused by repetitive use of muscles (running)

pathophysiological process of compartment syndrome

connective tissue around muscle compartments DOES NOT stretch

• a small amount of bleeding within the compartment can lead to increase in pressure

• capillary blood flow is compromised with any pressure increase

• edema of the soft tissue further raises pressure → compromising venous & lymphatic drainage of injured area

• if pressure continues to increase → compromise arteriole perfusion →further ischemia

anterior compartment

tibialis anterior, EDL, EHL

lateral compartment

peroneal m. & n.

deep posterior compartment

tibialis posterior, FHL, EDL, tibial n.

superficial posterior compartment

gastroc, soleus, plantar is

compartment syndrome can occur in..

any of the lower leg compartments

chronic compartment syndrome improves with

rest/reduction in training

general symptoms of acute compartment syndrome

• pain does not improve w/ medication

• swelling & tension of soft tissues

• pain & loss of voluntary movement (typically severe)

anterior & lateral CS symptoms

• pain is at injury site - radiates along anterior/lateral aspect of shin

• numbness & parasthesia possible if anterior tibial and/or deep peroneal n. are impacted

posterior CS symptoms

• pain at injury site & radiating posterior

• sural n. involvement - compromised sensation to lateral foot & distal calf

• tibial n. - plantar surface of foot sensation loss & pain

general ACS objective findings

• 5 P’s: pain, paralysis, paresthesia, pallor, & pulselessness

• impaired capillary refill >3 secs

• decrease acuity to two-pt discrimination

• (pulselessness may not be evident unless very severe)

anterior ACS objective findings

• decreased ankle DF (tibialis anterior) w/ possible foot drop

• paresthesia in webspace of first & second toes

• swelling

• decreased toe extension

posterior ACS objective findings

• decreased function of PF & foot inverters

• paresthesia at plantar surface of the foot

• decreased tow flexion

• pain w/ stretch

• pain w/ muscle activity

ACS medial management

• imaging - Stryker catheter can be inserted into the compartment to measure pressure level

• surgery is necessary to avoid ischemic injury

ACS PT management

• will occur only AFTER medical management

• no specific guidelines - individual to needs of pt

• correct biomechanical issues

• proper footwear to avoid excessive pronation

• education on appropriate training load

Achilles rupture MOI

• typically during a quick change of direction → ankle forced into DF while gastroc is contracting

• landing on PF foot

Achilles rupture risk factors

• previous Achilles rupture

• other major tendon rupture

• recent local corticosteroid injection

• type II DM

Achilles rupture symptoms

• patient may report feeling they were kicked/hit in ack of the leg

• potentially audible snap/pop

• may or may not be able to WB

Achilles rupture objective findings

• if able to walk - will lack push off

• + Thompson Test

• may see gastroc “balled up” into proximal calf

• May be able to palpate gap in tendon

Achilles rupture medical management

• imaging - typically not necessary if physical exam is enough

  • MRI may be used if concern for re-rupture or if significant time has passed between injury & when pt is evaluated

• surgery - Achilles tendon repair

• non-surgical - may be recommended for older pt or pt w/ low activity levels

  • cast for 2 weeks, followed by functional brace

Achilles rupture PT management

• post-op & pt being treated conservatively will progress similarly (likely have protocol from surgeon)

• focus on gradually regaining ROM & strength

  • avoid gastroc stretching in early phases to prevent tendon from healing in lengthened position

  • focus on accessory motion & soleus stretching

  • slow & controlled movement