BPK 142 Week 4

Bones

Bones

Tibia and Fibula

Articulations

• Tibiofibular joints

  • Superior (proximal) and inferior (distal)

  • Syndesmosis joint (distal only)

Ligaments

• Superior & inferior and posterior tibiofibular ligaments

• Also interosseus membrane

Periosteum

Forms the outer surface of bone and endosteum lines the medullary activity

Periosteum: Outer Fibrous Layer

• Contains blood vessels, nerves, lymphatic vessels that nourish bone

• Contains sharpey’s fibres that attach periosteum to bone AND ligaments and muscle tendons to bone

Periosteum: Inner Cellular Layer

• Responsible for bone repair and growth

• Cells it contains are osteoblasts which lay down new bone cells as bones grow or repair when damage

Bone cells

• Osteocyte

• Osteoblast

• Osteogenic order

• Osteoclast

Osteocyte

Maintains bone tissue, release calcium (becomes trapped)

Osteoblast

Forms bone matrix

Osteogenic cell

Stem cell

Osteoclast

Reabsorbing old bones (responds to stress)

Compartments

• Anterior Compartment

  • Muscles for dorsiflexion, toe extension

  • Anterior tibial artery, deep peroneal nerve

  • Tight

• Posterior Compartment

  • Loose

  • Plantarflexors, inverters, toe flexors

  • Posterior tibial artery, tibial nerve

• Lateral

  • Everters (peroneal muscles), superficial peroneal nerve

Interosseous membrane

Forms posterior border for anterior compartments. Holds bone together “tough tissue”

Anterior compartment of lower leg

• Tibial anterior, EHL, EDL, deep peroneal nerve, anterior tibial artery

Superficial posterior compartment of lower leg

• Gastrocnemius and soleus

Deep posterior compartment of lower leg

• Tibialis posterior, FHL, FDL, tibial nerve, posterior tibial artery

Lateral compartment of lower leg

• Peroneus longus and brevis, superficial branch of peroneal nerve

Contusion

• History: Direct blow

• Symptoms: Pain, tenderness, swelling, bruising, disability

• Diagnosis: fracture

• Treatment: POLICE, Padding, ROM, strengthening, ROM, Physio?

• Complication: Anterior compartments syndrome

Strain

• History: Sudden stop or start

  • Most common = Gastrocnemius and soleus muscolotendinous junction or medial soleus/ tibialis posterior/ posterior/ FDL muscle belly

• Symptoms: Pain(increased with movement), Tenderness, step deformity, Bruising, Limp, snap wth 2nd or 3rd degree injury and resisted ROM

• Treatment: POLICE, taping, phyio, ROM exercises, rehab, ice compression and crutches

Achilles Tendinopathy

• The term referred to achilles tendon: tendon is overloaded in some way

• Symptoms: Pain and stiffness, tendon feels warm. Weakness with resisted plantar flexion(toe raises), morning stiffness or after sitting for prolonged period of time. Chronic = thickening of tendon

• Treatment: Must reduce stress on tendon. Address any biomechanical issues, footwear, orthotics, Ice to decrease inflammation, ultrasound increase blood flow, cross friction massage, eccentric program

Achilles Tendinitis

Acute inflammation of achilles tendon

Achilles Tendinosis

Most people with achilles tendon pain have achilles tendinosis. No inflammatory cells present, collagen fibres in achilles tendon are disorganized, scarred, degenerated

Achilles tenosynovitis

Inflammation of achilles tendon sheath, causes fibrosis and scarring that restricts tendon’s motion within the sheath = stiffness

Eccentric Loading Program for Achilles Tendinopathy

• Assisted raising onto both feet

• Weight transferred to injured leg

• Non-assisted lowering

• Starting with 1 set of 10 reps, increasing to 3 to 5 sets of 10 reps

Achilles Rupture

• History: Associated in stop and go sports, Usually 30 or older athletes. Associated history of chronic inflammation, achilles tendinopathy

• Symptoms: Snap, pop, feeling like kicked, point tenderness, discolouration, swelling. Toe raising impossible on injured side and indent, positive Thompson test

• Treatment: Referral to hospital ASAP, if surgery, needs to be done very soon, POLICE, walking boot 12 weeks

Exercise Induced Lower Leg Pain

• Medial Tibial Stress Syndrome

• Stress Fracture

• Chronic Extertional Anterior Compartment Syndrome

  • Contributing Factors:

    • Poor running mechanics

    • Inappropriate footwear

    • Foot shape and biomechanics

    • Lower limb structural abnormalities

    • Muscle tightness and imbalance

    • Poor conditioning/ overweight

    • Inadequate warm-up and training errors

    • Terrain and training surfaces

Stress Overload Cycle

Muscle Fatigue → Loss of Shock Absorption → Structural Stress to Bone → Remodelling Process → Pain → Voluntary or Involuntary Disuse → Muscle Inhibition/ Atrophy

Shin Splints

• Medial Tibial Stress Syndrome

  • General Characteristics

    • Syndrome (several causes such as periostitis, strains, cortical bone microfractures due to overuse)

    • Predispositions = hard surfaces, hard surfaces, poor footwear, obesity, heredity

Medial Tibial Stress Syndrome

• Symptoms: Aching pain, worse with activity, Tenderness

• Grade of Shin Splints:

  • Grade 1 - dull pain 2-3 hours after activity

  • Grade 2 - pain before and after exercise, doesn’t affect performance

  • Grade 3 - pain before, during and after exercise, affects performance

  • Grade 4 - Severe pain, can’t participate

Medial Tibial Stress Sydrome Treatment

• DDx: Stress fracture, Chronic anterior compartment syndrome

• Treatment: Rest, NSAIDs, physiotherapy, Orthotics if needed, Correct other factors as needed and gradual return to activity

Tibial Stress Fractures

• History: Overuse (running, jumping)

• Symptoms: Aching pain, worse with exercise, possible history of high mileage, speed, hard surface training, Tenderness (focal), X-Ray positive (but many have fracture and negative X-Ray at first). Bone scan positive (SENSITIVE; not specific to fractures however)

• DDx: Shin Splints

• Treatment: Adequate rest (Walking boot? Cast? Walk only?), Correcting of etiologic factors, Alternating of etiologic factors, Alternate program for fitness and slow return to activity as tolerated

Bone Fracture

The concept of a stress fracture is a healing failure continuum. Normal bone -Stress reaction → Stress Fracture → Full (Acute) Fracture. Osteoclastic activity → Osteoblastic activity. Decreased bone mass perpetuates the problem

Anterior Compartment Syndrome Causes + Symptoms

• =ischaemia of muscles

• Causes: Internal volume: Hemorrhage from fracture, swelling from burns, contusion, tumour. External: Decreased volume: tight casts, bandage dressing. Overuse(excessive running)

• Symptoms: Pain(deep,”boring”) worse with exercise, slow to resolve(around 5-10 min), Tenderness, Weakness (Dorsiflexion, Toe Extension), Numbness(area of between 1st of 2nd toe). Diminished circulation (Dorsalis artery)

5 P’s Of Compartment Syndrome Symptoms

• Pain: Out of proportion for their injury, pain with rest or with passive stretch in suspect compartment

• Paresthesias: May be earliest subjective complaint due to increase pressure on nerve in tight compartment

• Paralysis: Also sign of muscle and nerve dysfunction, difficult to differentiate from muscle guarding as a result of pain

• Pallor and Pulselessness: Implies arterial insufficiency. Once pulses are diminished, the damage has been done

Compartment Syndrome: Pain

• Pain with passive muscle stretching

• Pain out of proportion relative to injury

• Progressive

• Not relieved by immobilization

Anterior Compartment Syndrome Treatment

• Chronic Exertional Compartment Syndrome

  • Adequate rest

  • Correct predisposing factors

  • Physician to access and monitor

  • Physiotherapy

  • Slow return to activity as tolerate

• Acute (Acute & Acute Exertional Compartment Syndrome)

  • Potential surgical emergency

  • NPO & transport to MD ASAP

  • May need fasciotomy

  • Then treat otherwise as for chronic

Compartment Pressure Testing

Most widely used diagnostic criteria for determining chronic exertional compartment syndrome were pressure measurements of >15 mmHg before exercise, >30 mmHg at 1 minute after exercise & >20 mmHg after 5 minutes after exercise

Acute Fractures

• Hx: Kick, Fall, Ankle Sprain

• Symptoms: Pain, tenderness (focal), Bruising, swelling, Crepitus?, Deformity?

• Treatment: Recognize, Stabilize, Transport to hospital