ATH 267 Final Exam

Foot injuries: general history questions

-Location of pain- heel, foot, toe, arches?
-Training surfaces or changes in footwear?
-Changes in training, volume, or type?
-Does footwear increase/decrease comfort?

Foot injuries: observations

-Does the athlete limp? Pes planus/cavus?
-Is foot alignment normal?
-Deformities, swelling, discoloration?
-What does the wear pattern look like on the shoe? Is the wear symmetrical?

Foot injuries: palpation

-Bones first!
-Checking for deformities and areas of tenderness
-After bones, then palpate soft tissue (muscles, tendons, ligaments)
-Check for point tenderness, swelling, muscle spasms or guarding
-Circulation (dorsal pedal pulse-anterior surface of ankle and foot)

Retrocalcaneal Bursitis

-Inflammation of the bursa beneath the Achilles tendon
-Result of pressure and rubbing of shoe heel counter of a shoe
-Exostosis may develop

Retrocalcaneal Bursitis S+S

-Signs of inflammation, tender, palpable bump on calcaneus, pain w/ palpation superior and anterior to Achilles insertion, swelling on both sides of heel cord
-MUST differentiate from Sever's disease/apophysitis

Retrocalcaneal Bursitis Care

-Routine stretching of Achilles, heel lifts to reduce stress, donut pad to reduce pressure
-Select different footwear that results in increasing or decreasing maximal dorsiflexion

Sever's disease

Chronic inflammation of Achilles insertion on heel, palpable pain in different location

Plantar fasciitis cause

-Change from rigid supportive footwear to flexible footwear
-Poor mechanics or structure (running technique, leg length, pronation, inflexible)
-Changes in training surface

Plantar fasciitis S+S

-Palpable pain on/in medical heel
-INCREASED PAIN IN MORNING, loosens after first few steps
-Pain with dorsiflexion

Plantar fasciitis care

-Extended treatment (8-12 weeks) is required
-Orthotics, but not good at first since foot is tender
-Simple arch taping, use of a night splint to stretch, keeps foot in dorsiflexion
-Walking boot or orthoplast
-Stretching/strengthening into dorsiflexion
Vigorous heel cord stretching and exercises that increase great toe dorsiflexion
-Medications/NSAID's
-Target active inflammation since chronic

Metatarsal Fracture cause

-Direct force or by placing twisting/torsion stresses on bone
-Usually resulting in transverse or spiral fractures

Metatarsal Fracture signs

-Generally present with swelling, pain, point tenderness, and possible deformity
-X-ray necessary to distinguish fx from sprain

Metatarsal Fracture care

-Immobilization for 3-6 weeks

Jones Fracture

-Fx at base (proximal head) of 5th metatarsal
-Styloid process off of base of the 5th

Jones Fracture cause

-Inversion or high rotational forces
-Common with soccer
-Often happens w/ ankle sprains

Jones Fracture S+S

-Immediate swelling, pain
-May feel a "pop"
-Hard to heal due to poor blood supply in this area
-Always palpate base of the 5th with an ankle sprain!

Jones Fracture care

-6-8 weeks non-weight bearing with cast
-If it does not heal, surgery is common (screw)

Metatarsal Stress Fracture

-March fx: 2nd metatarsal stress fracture
-Location: usually distal third of bone

Metatarsal Stress Fracture cause

-Change in training surface
-Often result of structural deformities of the foot

Metatarsal Stress Fracture S+S

-Pain + tenderness along second metatarsal
-Pain with running and walking
-Continued pain/aching with NWB
-May be some swelling

Metatarsal Stress Fracture care

-Determine cause of injury
-Gradual return to play
-Rest 2-4 weeks
-Return to running should be gradual over 2-3 week period with appropriate shoes

Bunion (Hallux Valgus Deformity) cause

-Exostosis of 1st metatarsal head
-Associated with forefoot varus; shoes that are too narrow, pointed or short
-Bursa becomes inflamed and thickens, enlarging joint, and causing phalangeal malalignment

Bunion S+S

-Tenderness, swelling, and enlargement of joint initially
-As inflammation continues, malalignment increases, causing pain with walking

Bunion care

-Correct fitting shoes, orthotics, padding, splint between 1st and 2nd metatarsal
-Surgery may be required

Morton's Neuroma cause

-Thickening/irritation of nerve sheath
-Commonly occurs between 3rd and 4th met heads

Morton's Neuroma S+S

-Burning, abnormal sensations and severe intermittent pain in forefoot
-Pain relieved with NWB
-Toe hyperextension increases symptoms
-Will not like being in shoes

Morton's Neuroma Care

-Teardrop pad can be placed between met heads to increase space, decrease pressure on neuroma
-Shoes with more room at met heads

Turf toe cause

-Hyperextension injury resulting in sprain of 1st metatarsophalangeal joint
-May be the result of single or repetitive trauma, but is normally chronic

Turf toe S+S

-Pain and swelling increases during push off in walking, running, and jumping
-May have weird slapping gait

Turf toe care

-Stiff shoe
-Taping the toe to prevent dorsiflexion
-Result and discourage activity until pain free
-3-4 weeks may be required for pain to subside

Callus cause

-Friction
-Painful as fatty layer loses elasticity and cushioning effect
-Vulnerable to tears and cracks and possible blister development underneath

Callus care

-Massaging with small amounts of lotion
-Standing or pumicing- care must be exercised

Callus prevention

-Shoes that fit appropriately
-Wear at least one layer of socks
-Apply petroleum jelly to reduce friction

Blister cause

-Shearing forces on skin, results in development of fluid accumulation between layers of skin
-Wearing appropriate footwear (socks and shoes) and applying lubricants may help to reduce friction

Blister care

-Reduce friction (apply lubricants, cover w/ tape, band-aid, donut pad)
-Avoid puncturing to prevent friction
-Puncturing may be necessary if pressure buildup is too great and is causing excessive pain: sterile procedures and good wound hygiene essential

Ingrown toenail cause

-Leading edge of nail grows into nearby soft tissue

Ingrown toenail care

-Wider shoes
-Correct nail trimming
-Should be cut short enough that it is not irritated by shoes or socks
-Nail should be left sufficiently long + not cut too short so that there is no penetration into soft tissue
-Soak in warm soapy water
-Pack toenail w/ cotton in order to lift nail away from soft tissue
-Cutting a "v" notch towards the infected side, will allow nail to grow towards middle

Recognition and Management of Specific Injuries

-Foot problems are associated with improper footwear, poor hygiene, anatomical structural deviation or abnormal stresses
-Sports place exceptional stress on feet
-AT's must be aware of potential problems and be capable of identifying, ameliorating, or preventing conditions

Subungual hematoma cause

-Dropping object on toe, kicking another object, improper footwear
-Repetitive shear forces on toenail

Subungual hematoma S+S

-Accumulation of blood underneath toenail
-Likely to produce extreme pain and ultimately loss of nail

Subungual hematoma care

-PRICE immediately to reduce pain and swelling
-Relieve pressure within 12-24 hours (lance or drill nail-must be sterile to prevent infection, cuttery tool or scalpel)

Ankle/mortice joint

-Tibia, fibula, talus
-Main ankle joint
-Plantar and dorsiflexion

Subtalar joint

-Talus, calcaneus
-Inversion and eversion

Ligament's purpose

-Provide PASSIVE stability

Deltoid/medial ligament

-Medial side stronger/has more stability

Lateral collateral ligaments

-Anterior talofibular (most commonly sprained)
-Calcaneofibular
-Posterior talofibular

Tibiofibular ligament

-Connects tibia and fibula directly over the talus
-Anterior and posterior

Ankle/lower leg history questions

-Past history
-Ask a lot more questions for ankle
-MOI (roll in/out? Did you step on someone?)
-When does it hurt?
-Type of, quality of, duration of pain?
-Sounds or feelings?
-How long were you disabled?
-Swelling? Are you normally a sweller?
-Previous treatments?
-Taped or braced?
-What shoes were you wearing?

Ankle/lower leg observations

-Postural deviations?
-Gena valgum (knock kneed) or genu varum (bow legged)?
-Is there difficulty with walking?
-Deformities, asymmetries, or swelling?
-Color and texture of skin, heat, redness?
-Is ROM normal?
-In obvious pain?
-Pez planus or pavus?

Ankle/lower leg palpation

-Not as important
-Start with bony, then move to soft tissue anatomy

Sprains (ankle/lower leg)

-Single most common injury in athletics, caused by sudden inversion or eversion movements
-Can happen anywhere there is a ligament in ankle/foot
-Most common MOI is inversion plantarflexion, injuring ATF ligament most commonly
-Occasionally the force is great enough for an avulsion fracture to occur with the lateral malleolus

Grade 1 ankle sprain

-Mild pain and disability; weight bearing is minimally impaired, point tenderness over ligaments and no laxity

Grade 2 ankle sprain

-Feel or hear pop or snap; moderate pain w/ difficulty weight bearing; tenderness and edema
-Possible tearing of the anterior talofibular and calcaneo- fibular ligaments

Grade 3 sprain

-Least common
-Severe pain, swelling, discoloration
-Unable to bear weight
-Instability due to complete ligamentous rupture

Eversion ankle sprain

-Not as common
-Bony stability and ligament strength make this injury more rare
-Eversion force resulting in damage to deltoid
-Slower to heal than inversion ankle sprains
-Doesn't swell much
-Possible fractures:
-Avulsion fx of the tibia
-Transverse fx of fibula

Syndesmotic/high ankle sprain

-Anterior tibiofibular ligament sprain
-Injury to the distal tibiofemoral joint (anterior/posterior tibiofibular ligament)
-Debilitating
-Torn w/ increased external rotation or dorsiflexion
-Jamming of the talus into mortice
-May require extensive period of time in order to return to play

Syndesmotic/high ankle sprain care

-PRICE
-Avoid weight bearing for at least 24 hours
-Return to participation should be gradual and dictated by healing process
-Do not let them back in the game no matter the grade
-Looks completely normal, not a lot of swelling/ecchymosis
-Finger trick= how many weeks out for

Tibial and fibular fractures cause

-Direct blow or indirect trauma
-Tibial fx may be more common
-Fibula is a NWB bone, so they can still walk on it

Tibial and fibular fractures S+S

-Pain, swelling, bruising, hear/feel pop, instability, deformity
-Often an open fracture
-Many tibial fractures need surgery

Tibial and fibular fractures care

-Emergency response!
-Splint to immobilize, ice, medical referral
-Restricted weight bearing for weeks/months depending on severity

Tibia or fibula stress fractures cause

-Rare in fibula, but often occurs in tibia
-Have them NWB for 4-6 weeks (boot and crutches)

Tibia or fibula stress fractures S+S

-Pain with activity
-Pain more intense after exercise than before
-Point tenderness, difficult to discern bone and soft tissue pain
-Bone scan (won't show on scan immediately but will over time)

Tibia or fibula stress fracture care

-Partial or NWB as needed
-Weight bearing may return when pain subsides
-After pain free for 2 weeks, athlete can gradually return to activity
-Biomechanics must be addressed

Medial Tibial Stress Syndrome (shin splints)

-Diffuse pain on medial border of distal tibia
-Caused by repetitive microtrauma
-Weak muscles, improper footwear, training errors, biomechanical abnormalities
-Can progress to stress fractures
-Walking may be painful
-Morning pain and stiffness

Shin splints care

-Physician referral for x-rays and bone scan
-Activity modification
-Correction of abnormal biomechanics/flexibility
-Ice massage to reduce pain and inflammation
-Important to find out the actual pathology to injury:
-You can ice cup, but what is the actual cause?
-Orthotics may help

Compartment syndrome

-Traumatic syndrome due to direct blow or excessive exercise
-Mau be classified as acute, acute exertional, or chronic
-Excessive swelling compresses muscles, blood supply, and nerves
-Like a twizzler pull/peel

Compartment syndrome S+S

-Deep aching pain
-Tightness/swelling
-Pain with passive stretching
-Weakness with foot and toe extension
-Decreased circulation
-Numbness is dorsal region of foot
-5 p's

5 p's

-Pressure
-Pain
-Paralysis
-Paresthesia (numbness)
-Pallor (skin white/pale)
-Pulselessness

Acute exertional compartment syndrome care

-Soft tissue massages and stretching

Exertional compartment syndrome test

-Slice in area, put in probe, then have them run

Acute compartment syndrome treatment

-MEDICAL EMERGENCY!
-NO COMPRESSION WRAPS

Acute exertional/chronic compartment syndrome care

-Conservative treatment, possible surgery
-NO COMPRESSION WRAPS

Tendinopathy common sites

-Achilles
-Peroneal (lateral side)
-Anterior tibialis
-Posterior tibialis

Tendinopathy cause

-Singular cause or overuse
-Overuse most common

Tendinopathy S+S

-Inflammation
-Crepitus (crunchy/creaky, common in Achilles)
-Pain with AROM and PROM

Tendinopathy care

-PRICE
-Tape
-Orthotics for foot mechanic

Achilles tendinopathy cause

-Inflammatory condition involving tendon, sheath, or paratendon
-Tendon is overloaded due to extensive stress
-Presents with gradual onset and worsens with continued use
-Decreased flexibility exacerbates conditioned

Achilles tendinopathy S+S

-Generalized pain and stiffness, localized proximal to calcaneal insertion, warmth and painful with palpation, as well as thickened
-May progress to morning stiffness

Achilles tendinopathy care

-Resistant to quick resolution due to slow healing nature of tendon
-Must reduce stress on tendon, address structural faults (orthotics, mechanics, flexibility)
-Aggressive stretching and use of heel lift may be beneficial
-Use of anti-inflammatory medications is suggested

Achilles tendon rupture cause

-Occurs with sudden stop and go; forceful plantar flexion with knee moving into full extension
-Commonly seen in athletes over 30 years old
-Patient generally has history of chronic inflammation

Achilles tendon rupture S+S

-Sudden snap (feels like kick in leg) with immediate pain and rapidly subsides
-Point tenderness, discoloration, swelling, decreased ROM (won't have control of foot at all)
-Obvious indentation and positive Thompson test (squeeze calf, and hope for foot to plantarflex)
-Obvious deformity in calf, looks like ball rolled up in calf

Achilles tendon rupture care

-Usually involves surgical repair
-Non-operative treatment consists of PRICE, and a NWB cast for 6 weeks to allow proper tendon healing
-Long rehabilitation
-Return to play 4-6 months
-Surgical repair is more effective than putting athlete in a walking boot

Knee joint

-Complex joint that endures great amounts of trauma due to extreme amounts of stress that are regularly applied
-Stability is due primarily to ligaments, joint capsule, and muscles surrounding the joint

What is the knee designed for?

-Stability with weight bearing
-Mobility in locomotion

What parts of the knee perform shock absorption?

-Medial meniscus
-Lateral meniscus
-Articular cartilage of femoral condyles

Assessing the knee joint

-MOI tells a lot!
-Knowing the common injuries, their unique cause, symptoms, etc, will help you quickly narrow down the possibilities

Knee- History

-Recurrent or chronic injury?
-What is your major complaint?
-When did you first notice the condition?
-Is there recurrent swelling?
-Does the knee lock/catch? (w/ meniscus injury, athlete may try to kick it out)
-Is there severe pain?
-Grinding or grating? (Condro, posterior side of patella, flexion/extension)
-Does it ever feel like giving way? (meniscus)
-What does it feel like on stairs? (Because knee is bending)
-Any training or footwear changes?

Knee- Observation

-Walking, half squatting, going up/down stairs
-Signs of inflammation, two main types:
-Joint effusion: obvious swelling inside of synovial joint capsule; structure inside of joint capsule that is damaged, internal damage/all together
-External damage, patella, ligaments, menisci, articular cartilage, bursa

Joint capsule

-Fibrous lining around joint that holds synovial fluid inside the joint
-Purposes: reduces friction, absorb shock, transport nutrients/waste

Knee- palpation

-Position: supine or sitting at edge of table with knee flexed to go 90 degrees
-Bones
-Soft tissue
-Lateral ligaments
-Joint line: meniscus, articular cartilage
-Muscles

Medial collateral ligament sprain (Cause? Special test?)

-Cause: severe lateral blow or outward twist, plant and twist motions, most common in lineman
-Special test: valgus stress test
-Lateral blow can also cause lateral meniscus tear

MCL signs/grade 1 sprain

-Stable valgus test
-Little to no joint effusion or swelling
-Some joint stiffness
-Point tenderness
-Relatively normal ROM

MCL grade 2 sprain

-Partial tear
-Slight laxity, doesn't feel stable/right
-Slight effusion
-Moderate to severe joint tightness w/ decreased ROM
-Pain along medial aspect of knee

MCL grade 3

-Complete rupture or mostly ruptured
-Complete loss of medial stability
-Possible added meniscus tear
-Minimum to moderate effusion
-Immediate pain followed by ache
-Loss of motion due to effusion and hamstring guarding
-Not necessarily surgical

Lateral collateral ligament sprain cause

-Not very common
-Varus force, generally w/ the tibia internally rotated
-Direct blow is rare, hit from medial side, turn and twist with external rotation

LCL signs

-Pain and tenderness over LCL
-Swelling and effusion around the LCL
-Special test: varus stress test
-Grade 1-3 similar

Anterior cruciate ligament sprain

-MOI: athlete decelerates with foot planted and turns forcing tibia into internal rotation
-Foot out, turning internally
-Tackles, or non-contact plant and twist

Tibial translation (ACL)

-The glide of the tibial plateau relative to the femoral condyles, shifting of tibia forward
-May be linked to inability to decelerate (when slowing down, ACL can go)

ACL tears in men vs women?

-Male: since more males play sports, number is higher
-Female: But, more likely to happen in women
-Has to do with hamstring strength, if they aren't strong enough to hold tibia back/prevent it from sliding forward, ACL size, women have more hyperextension
-After a period, hormones make it more likely to tear
-May be linked to abnormal hamstrings to quadriceps strength, improper quad to hamstring ratio
-Femoral notch smaller in female = more likely to sprain

ACL sprain cause

-Femoral notch
-ACL size
-Laxity
-Malalignments (Q-angle= wide hips, more pressure on medial knee)
-Faulty biomechanics
-Also involves damage to other structures including meniscus, capsule, MCL, articular surface