Lower Leg, Ankle, Foot, and Toes Pathologies

close chain pronation

internal tibial rotation, knee flexion, and hip internal rotation (pronation distortion syndrome/pes planus)

close chain supination

external tibial rotation, knee extension, and hip external rotation (pes cavus)

Os peroneum

small sesamoid bone located in the peroneus tendon just proximal to the cuboid

Os trigonium

an extra, often triangular, accessory bone located at the back of the ankle, connected to the talus bone

Peroneus quartus

small muscle that arises from the peroneus brevis and inserts on the calcaneus

Ottowa Ankle Rules

1. patient is unable to walk 4 streps after injury and at time of exam

2. pain during palpation of malleoli

3. pain is elicited during palpation over styloid provess or navicular

signs and symptoms of ankle and leg fractures

audible noise, pain at the site or radiating, crepetis, point tenderness, misalignment

initial treatment of ankle and leg fractures

immobilization and refer

RTP for ankle and leg fractures

cleared by physician, near full ROM, strength, and endurance

MOI of stress fractures

chronic onset secondary to repent of running or jumping

s/s of stress fractures

isolatged pain, decreased muscular strength, cramping, crepetis, point tenderness

special tests for stress fractures

squeesze test, bump test

imaging for strerss fractures

radiographs, bone scans

ddx for stress fractures

MTSS, exertional compartment syndrome

initial tx for stress fracture

POLICE, immobilize qith boot/aircast/ crutches

RTP for stress fracture

dependent on pain and tolerance

MOI of lateral ankle sprain

inversion, plantarflexion

s/s of lateral ankle sprain

popping, localized pain, diffuse (ATF and PTF) or little swelling (CF), pain in medial ankle, point tenderness over the lateral ligaments

special tests for lateral ankle sprain

anterior drawer, talar tilt, subtalar joint play tests

imaging for lateral ankle sprain

MRI, ultrasound, radiographs

ddx for lateral ankle sprain

syndesmosis sprain, sublux peroneal tendon, fracture

initial tx for lateral ankle sprain

POLICE, control edema, taping/bracing rehab

RTP for lateral ankle sprain

based on functionality

mechanical ankle instability

structural damage - bone, ligaments, etc ; muscles are still acting properly

functional ankle instability

good structure, poor muscle function, typically show a delayed muscular response due to inflammation, muscle inhibition

chronic ankle instability

recurrent ankle sprains leading to instability.

copers ankle instability

people who roll their ankle and keep going unbothered

MOI of syndesmotic sprains

dorsifelxion, internal rotation

s/s of syndesmotic sprain

point tenderneass, swelling, decreased AROM

special tests for syndesmotic sprain

external rotation test (kleigers), dorsiflexion compression test, squeeze test

imaging for syndesmotic sprain

radiograph

ddx for syndesmotic sprain

lateral ankle sprain, fib fx, deltoid sprain

initial tx for syndesmotic sprain

POLICE, imobilization using crutches and a boot

RTP for syndesmotic sprain

dependent on severity, requires clearance

MOI of medial ankle sprain

eversion

s/s of medial ankle sprain

point tenderness in medial ankle, pain along medial joint line, localized swelling

initial tx of medial ankle sprain

POLICE, immbilize using crutches and a walking boot

RTP for medial ankle sprain

administer functional test, provide support if necessary

MOI for achilles tendon pathologies

acute (strain), chronic (tendinitis)

s/s for achilles tendon pathologies

pain, point tender, swelling, deformity, weak plantarflexion, pain pushing off

special test for achilles tendon pathology

thompson test, MMT

imaging for achilles tendon pathologies

MRI, ultrasound

ddx for achilles tendon pathologies

bursistis, avulsion fracture

initial tx for achilles tendon pathologies

POLICE, immobilize and or walking boot

RTP for achilles tendon pathologies

3rd decree strain requires physician clearance, less severe requires full ROM and strength

MOI for Sever's Disease

growth spurts/overuse

s/s for sever's disease

pain and point tenderness over posterior calcaneus, swlling, pain with weight baring, decreased dorsiflexion (AROM), weak plantarflexion (PROM), pain with push off

special test for sever's disease

thompson test, MMT, RROM

imaging for sever's disease

MRI

ddx for sever's disease

bursitis, avulsion fracture, achilles tendinopaty

initial tx for sever's disease

POLICE, impobilize with crutches/scooty and or walking boot

RTP for sever's disease

requires clearance

MOI for Os Trigonium

acute or chronic onset in adolescents, repeated plantar flexion

s/s for os trigonium

pain over posterior talus, swelling, pain with toe- off, point tender over achilles, pain with plantarflexion

imaging for Os Trigonium

radiographs or MRI

ddx for os trigonium

achilles tendinopathy, lateral ankle instability, arthrits, tarsal tunnel, talus fracture

initial tx for os trigonium

POLICE, pain management, immboliziing using crutches and walking boot

RTP for os trigonium

as tolerable

MOI for Peroneal Tendonopathy

acute or chronic, dorsiflexion/eversion OR plantarflexion/inversion

s/s for Peroneal Tendonopathy

pain and point tender to lateral malleolus, subluxation, ROM and MMT reproduce symptoms

special test for peroneal tendinopathy

ROM and MMT

Imaging for peroneal tendon pathology

ultrasound and MRI

ddx for peroneal tendenopathy

os peroneum syndrome, lateral ankle sprain, fib fx, calcaneal process fx, osteochondritis dissecans

RTP for peroneal tendinopathy

complete fucntional testing pain free with full ROM or as tolerable

MOI of deep peroneal nerve compression

compartment syndrome, high arch, tight shoelaces

s/s of deep peroneal nerve compression

loss of dorsiflexion, pain or purning with plantarflexion, pain with PROM plantarflecion, toe ext and dorsiflexion weakness

special test for deep peroneal nerve compression

deep peroneal nerve compression

initial tx for deep peroneal nerve compression

refer

RTP for deep peroneal nerve compression

deep peroneal nerve compression

MOI for superficial peroneal nerve palsy

ankle sprains

s/s of superficial peroneal nerve palsy

sensory changes along lateral leg and dorsum of foot, weakness with eversion, pain with plantarlfexion and inversion

initial tx for superficial peroneal nerve palsy

refer

RTP for superficial peroneal nerve palsy

cleared by physician or no symptoms

MOI for osteocondritis dissicans

h(x) of previous unjuty or unkonwn cuase

s/s of osteocondritis dissicans

replicate an ankle sprain, joint pain, swelling with activity, locking, clicking, decreased ROM

imaging for osteocondritis dissicans

x-ray, MRI

ddx for osteocondritis dissicans

ankle sprain

initial tx for osteocondritis dissicans

POLICE

RTP for osteocondritis dissicans

physican clearance

prediposing factors for tendinopathies

improper mechanics, abnormal alignment

MOI for tendinopathies

overuse, friction, traction

s/s of tendinopathies

pain, point tender, crepetis, decreased ROM, swelling, pain with passive stretch, AROM, or RROM

special tests for tendinopathies

ROM and MMT

imaging for tendinopathies

MRI

ddx for tendinopathies

strains, other tendinopathies

initial tx for tendinopathies

rest, thermotherapy, iastm, immobilize

RTP for tendinopathies

as tolerable

MOI for MTSS

chronic

s/s of MTSS

pes planus, rearfoot, forefoot, tenderness on tibia, swelling, decrease MMT, increase pain with dorsiflexion, pronation, or toe extension, pain at beginning of activity and returing after

special test for MTSS

navicular drop test

imaging for MTSS

radiograph, bone scan

ddx for MTSS

tibial stress fx, deep posterior compartment syndrome, DVT, popliteal artery entrapment

initial tx for MTSS

pain management, cross friction massage, calf stretching, arch taping, orthotics, IASTM, aircast

RTP for MTSS

as tolerable

MOI for DVT

acute, surgery , pregnancy

s/s of DVT

redness, swelling, tightness, increased temp

special test for DVT

homan’s sign

special test for DVT

homans sign

imaging for DVT

ultrasound (gold standard), CT, MRI, venograph

initial tx for DVT

refer asap, anticoagulants, surgery