MSK 1: Ankle Sprains and Plantar Heel Pain

75% of ankle injuries and 10-30% of all youth sports injuries are ___

ankle sprains

___ %of people develop persistent/chronic pain or instability after ankle sprains

20-40

grade 1 ankle sprain

can keep playing, no functional instability, 2-10 day recovery, usually dont come to PT

grade 2 ankle sprain

increased functional loss, swelling/effusion/tenderness, 10-30 day recovery, most common PT presentation

grade 3 ankle sprain

complete tear, unstable, involved multiple ligaments/capsule, restricted WB, 30-90 day recovery

most common ankle sprain

inversion/lateral ankle sprains

what is the lateral ankle sprain MOI

PF and INV

what ligaments are implicated in lateral ankle sprains

ATFL, CFL, PTFL (severe, rare)

inversion sprain intrinsic risk factors

limited DR ROM, dec ankle proprioception, dec balance

WE HELP CONTROL THESE

inversion sprain extrinsic risk factors

sport type, level of competition, field conditions

WE CANT CONTROL

pathologies associated with lateral ankle sprains

peroneal tendon injury, peroneal nerve issues, talar osteochondral lesion, distal fibula/lateral malleolus fracture, medial malleolus fracture, base of 5th fracture, sinus tarsi syndrome

with a lateral ankle sprain we get ___ laterally and ___ medially

distraction; compression

inversion sprains signs/symptoms

lateral ligament tenderness, swelling/discoloration in lateral ankle, painful/limited PF and INV ROM, painful/weak eversion MMT, + anterior drawer/talar tilt, antalgic gait

anterior drawer mostly tests for __ laxity

talar tilt mostly tests for ___ laxity but further PF can help bias ___

ATFL; CFL; ATFL

best treatments for ankle sprains

worst?

manual therapy, Therex; ultrasound

what is the focus of the acute/symptom modulation phase for non-operative treatment of inversion sprains

POLICE, immobilization/protected WB based on severity, AROM/PROM within pain free range

what can we progress to during the motor control phase for non-operative lateral ankle sprain rehab

strength, aggresive ROM, proprioceptive/NM training

our strength programs should include LE strength in ___ to encourage foot/ankle motor control

WB

when can the functional optimization phase of non-operative lateral ankle sprain treatment be initiated

normal ROM/strength, no/minimal pain

T/F: protective taping and bracing helps reduce risk of re-injury

T, by 50-70%

what can we begin to add in during functional optimization

jogging, inc intensity for strength,

when would someone be classified as having CAI

recurrent sprains/giving way for 6+ months

T/F: CAI always results from an increase of mechanical laxity

F, we can have functional CAI

what is the issue in functional CAI

disturbed proprioception (not laxity)

different approaches to CAI rehab

comprehensive (strength, ROM, NM control, functional tasks)

dynamic hop programs

traditional SL balance programs

ALL HAD IMPROVEMENTS

what is the operative treatment for lateral ankle sprains? when is this procedure indicated?

modified brostrom gould repair; persistent CAI/dont respond to conservative management

what are some concerns with modified brostrum?

elongation/weakness/chronic instability for elite athletes/large individuals

what is the post op WB progression after modified brostrum repair

NWB in splint (10-14 days)

PWB with boot/walker/crutches (4-6 weeks)

FWB in regular show with ASO (2-4 weeks)

what should we avoid in the initial 6 weeks after modified brostrum repair

PF, INV (ROM or full range strengthening)

what can we do during the inital 6 weeks after a modified brostrum

gentle ROM (not PF/INV), strengthen proximal musculature

when should full PF and INV be restored after modified brostrum

12 weeks

tf is sinus tarsi syndrome bruh

complication of chronic inversion sprains where talus displaces into sinus tarsi w/ pronation --> fibrosis and irritation in sinus tarsi

signs symptoms of sinus tarsi syndrome

point tenderness around lateral malleolus, over pronator, pain w/ ambulation that subsides w/ rest

how can we treat sinus tarsi syndrome

treat the over pronation (taping/orthotics), steroid injections

eversion sprain MOI

forceful eversion and or ER

what structures can be implicated in an eversion sprain

deltoid ligament, distal tib fib (interosseous membrane), avulsion of calcaneus (severe)

signs/symptoms of eversion sprain

TTP over deltoid ligament/distal dib fib area

swelling/ecchymosis over medial ankle

pain with DF/EV ROM

pain and weakness with INV MMT

+anterior drawer (if severe), ER test

antalgic gait

what do we often see in conjunction with disruption of the deltoid ligament complex

lateral ankle sprains, ankle syndesmosis injury, maisonneuve fracture, malleolar fracture

eversion sprain non operative treatment mirrors inversion principles EXCEPT

avoid EV/DF now, stregthen inverters, potentially longer immobilization

what structures are implicated in high ankle sprains

anterior distal tibfib ligament, distal interosseous membrane

high ankle sprain MOI

forced ER and or DF + leg IR

high ankle sprain signs/symptoms

TTP at distal tibfib, minimal swelling, pain with passive DF

what does the ER test screen for? what other test can we use to screen for this issue?

syndesmotic injury; compression test

what is the key difference in non operative high ankle sprains

prolonged protected WB, longer recovery/RTS time (despite no pain with ADLs)

what is the traditional (aggressive) operative treatment for high ankle sprains? what does that rehab look like?

syndesmotic screw fixation

splint for 10-14 days, PWB for 4-6 weeks, screw usually removed

what is a newer alternative to screw fixation? what are the advantages

tight rope

no second surgery to remove, less rigid --> more movement/earlier RTS

what does the timeline for tight rope operations look like

splint for 7-10 duays, WBAT in boot, RTS 6-10 weeks

what is turf toe

1st MTP hyperextension that injures plantar plate and sesamoids

turf toe MOI

forefoot on grount with 1st MTP extended and axial load applied through heel

what injuries can accompany turf toe

1st MTP varus/valgus, fractured/displaced sesamoids, hallux rigidus, lis franc

key exam findings indicating turf toe

acute pain swelling, difficulty with gait/push off, TTP distal to sesamoids, pain with extension A/PROM, 1st MTP dorsal glide lax

focus of the motor control phase for turf toe

proprioception/balance, intrinsic strength, ROM, progressive LE strength

when returning to sport-like activity during the functional optimization phase of turf toe rehab what should you start with

sagittal plane movement, before getting into cutting/pivoting/etc

when is surgery indicated for turf toe?

unstable (grade 3) injuries with loose body and unsuccessful at conservative management

turf toe post-op rehab protocol

immobilization and partial WB for 4-6 weeks

progressive WB and ROM after 6 weeks

strength initiated around 8-12 weeks

return to cutting 14-32 weeks (with stiff insert)

key features of plantar fasciitis

TTP at medial calcaneal tubercle

pain worst when WB first thing in the morning/after prolonged sitting

P! with DF+great toe ext

relief in slight PF

pes cavus/planus

Plantar Fasciitis MOI/Risk Factors

pes planus ___ the plantar fascia --> irritation

pes cavus leads to ___ shock absorption --> ___

limited ___ causes more MTP extension --> excess ___ on plantar fascia

limited MTP ___ places more stress on the fascia during gait

stretches; decreased

plantar fascia must absorb more shock

DF

tension

extension

what are some differentials for plantar fasciitis

calcaneal stress fracture, avulsion of fascia, calcaneus bone bruise, tarsal tunnel syndrome, fat pad syndrome, S1 radiculopathy referred pain, soft tissue, metastatic bone tumor

what can we use to test for plantar fasciitis?

windlass testing sitting then standing

best treatment approaches for plantar fasciitis

manual therapy, stretching, taping, night splints, strength (foot/ankle)

fat pad syndrome causes

age related changes, trauma (fall onto heel, repeated landing, training errors)

where is the fat pad

plantar heel below posterior calcaneus

main treatment for fat pad syndrome

activity modification, orthotic/shoes with increased cushion

what is tarsal tunnel syndrome

entrapment of tibial nerve as it passes through the tarsal tunnel

what can cause tarsal tunnel syndrome

edema, tendinitis, fracture, gout crystals, tumors

(basically anything that is going to occupy space in the narrow tunnel/impinge)

what can further aggravate tarsal tunnel syndrome? why?

excess pronation; tightens the flexor retinaculum

signs/symptoms of tarsal tunnel syndrome

shooting/burning along tibial n distribution

parasthesia of plantar foot

increase in symptoms w/ activity

increase symptoms with maximal DF+EV or with MTP/IP extension held for 10 secs

how can we treat tarsal tunnel syndrome

activity modification

treat inflammation

orthotic for over pronation

surgical release of flexor retinaculum