MSK II: Force/Load intollerance Foot & Ankle presentations

PT diagnosis

• tendinopathy = load

• photo 1:

  • injured tendon with collagen fibers all over the pale, theres no organization

  • extracellular matrix leads to unorganized of collagen while laying down

  • realign collagen fibers

  • lay down and respond to load

• photo 2:

  • this person had eversion

  • their body adapted to force over time and have this acetabularized talocrual joint

• photo 3: size difference with load and without

its all About the load

• “Your tissue capacity will only ever be as great as the load you’ve placed on it previously”

Load vs capacity

what does blue line on chart represent?

• the tendons capacity and the normal ability our tendons have for day to day activities

• warehouse job to sedentary job capacity decrease

• capacity has ability to change with stress/strain with exercise

what happens when load goes above capacity?

• injury

• a large load can cause tendinopathy or tear

• so if we do something we’ve never done before but run a marathon when we haven’t run in 3 years then our capacity wouldn’t be able to handle it and our load exceeds the capacity of the tendon

where do you start?

SINSS, specifcally Nature

1. Tensile Load- Store & Release Energy
2. Compressive Load- Interface with other structures
3. Tensile & Compressive Loads
4. Shear & Friction Load

4 types of stress

• midportion of achilles

• where tendon stores and release energy

• CPG

• where we exceed the capacity of the tendon is where we have injury

• Tensile or mid-substance pain will increase as the load increases
  (double leg heel raise < single leg heel raise < double leg hop <
  Single leg hop)

Tensile Load- Store & Release Energy

• tendon comes together with other structures pressing on each other

• more insertional achilles tendinopathy pressing against the calcaneus

• tibilias posterior is a tendon typically exposed to compressive load as it goes thru the tarsal tunnel

• rare in isolation

• Increased pain with stretch/excursion of the tendon

Compressive Load- Interface with other structures

Tensile & Compressive Loads

• Increased pain with repetitive low load
  movement

• sheath that covers the tendon itself it gets friction between the structures underneath it and causes pain and discomfort after that

Shear & Friction Load

when will tensile increase?

tensile will increase when load increases

when is tensile worse?

double leg heel raise < single leg heel raise < double leg hop < Single leg hop

what will increase compressive stress?

increase with stretch/excursion of the tendon

what to avoid with compressive stress

• unilateral movements in weight bearing (single leg, heel raise, and plyometrics)

• end range dorsiflexion

what helps with compressive stretch

• stretching helps (static)

• isometrics and isotonics in pain free range is okay but stay away from end range dorsiflexion

• heel raises help unload tendon

what to stay away with compressive & tensile stress together?

• isotonics or isometrics are okay but stay away from end range dorsiflexion

  • still give a heel lift

  • squats with wedge under heels

• pain with both

what increases pain in shearing/friction?

• swimming, riding bike, walking all increase pain

• stray away from repetitive low load movements

where is the pain?

• Palpation- Sensitive, Not Specific

• Achilles pain is localized- 2 fingers in mid tendon for mid- substance (tensile), 1 finger at insertion for insertional (compressive)

• Peritenon pain is more diffuse

is palpating more sensitive or specific?

sensitive - means that the test is good at detecting the disease when it is present

is there night pain with tendon related pain?

• Usually no night pain with mid-substance

• Can have pain and stiffness in the am.

  • Subsides within 30 minutes

does mid-substance pain get worse with or without activity?

• Mid-substance pain subsides with activity.

• Peritenon pain increases with activity

clinical practice guidelines

MAKE SURE TO READ

Tendon Specific Considerations- Achilles Tendon

tibialis posterior signs and symptoms

• Pain medial foot that worsens with activity

• May have redness, swelling, and localized tenderness over tib post tendon

• Rearfoot valgus, flattened midfoot, and forefoot abduction

what are cardinal signs of inflammation

May have redness, swelling, and localized tenderness over tib post tendon

what is signs or components of pronation

Rearfoot valgus, flattened midfoot, and forefoot abduction

if tibialis posterior is compressive what should be given to the patient ot help

give patient taping and towel

tibialis posterior stages- johnson classification

Pain, tenderness to palpation, edema in tendon region Can perform single leg heel raise

stage 1 johnson classifciation

• Tendon incompetence leading to a flexible deformity

• IIa: Rearfoot valgus. Unable to single leg heel raise. Correctable

• IIb: Rearfoot valgus and forefoot abduction. Unable to single leg heel raise. Correctable

• navicular drop or heel drop

stage 2 johnson classifciation

• Fixed (uncorrectable) deformity of the foot

• unaddressed for a long time

• use more manual therapy

  • talocrual or midfoot mobility

stage 3 johnson classifciation

• additional talocrural valgus deformity Early ankle degenerative changes

• permanent everted

stage 4 johnson classifciation

• Pain medial plantar region

• Unilateral

• Insidious onset

• Sharp/local pain with palpation

• Sharp/local pain upon WBing after period of NWB

• Pain gradually improves with activity, then worsens

• Pain with ext 1st MTP

• right on insertion of calcaneus and go on the arch with walking

• windlass test - astrik sign

• great toe extension, dorsiflexion mobs.

plantar fasica signs and symptoms

MAKE SURE TO READ

plnatar fascia clinical practice guidelines

• EdURep

• Educate

• Unload

• Reload

• Prevent

Management of Tendon Related Presentations

where to start reloading ?

• isometircs- pain free range

• isotonics NWB, then WB

how to prevent reinjury?

educate to not increase capacity

educate

dont tell them they have tears or tenonitis use tendinopathy

words matter

imaging doesnt tell the whole story

educate patients that there will be good and bad days PT is not a linear increase

remove the provactive load

Unload

limit fast loading

Tensile/mid-substance Tendinopathy

Limit stretch on the tendon

Compressive

• tape

• heel lift

• heel cup

• orthosis

• mobilize

• address movement coordination deficits

• increase cadence

other considerations to unload

Support muscle, Support arch

tape

Compressive (Tib Post, Achilles insertion

heel lift

plantar fasica

heel cup

Prefab or custom for plantar heel pain, Custom/hinged AFO/CAM boot for tib post- NOT MID SUBSTANCE OR INSERTIONAL ACHILLES

orthosis

joint and soft tissue restrictions

mobilize

what could be addressed with unload?

Address movement coordination deficits

what can we increase to unload?

Increase cadence- Running or walking

reload: 4 phase approach

how hard can someone perofrm isometric contraction

MVIC

what should pain level be normally when exercising?

5/10, increased pain isnt bad as long as its 5 or below

More than minimal pain during isotonic exercise

stage 1: isometric loading

indication to initiate

5x45 seconds, 2-3 times per day. Heavy Load. Progress to 70% MVIC. Start during unloading phase

stage 1: isometric loading

doseage

Minimal pain during isotonic exercise

stage II - Isotonic Loading

indication to initate

3-4 sets at 15 RM progressing to 6 RM, 3 days per week. 2 second shortening: 3 second lengthening. Isolated muscle ex > multi joint ex

stage II- isotonic loading

dosage

A: Adequate strength that is symmetric to other side
B: Load tolerance with intial energy-storage loading exercises (minimal pain during exercise that returns to baseline within 24 hours

stage III- energy storage loading

indication to initiate

• Progressively develop volume then intensity of relevant energy-storage exercise to replicate demands of activty limitation

• volume and intensity

• walking

• hopping but not jumping

stage III- energy storage loading

dosage

Load tolerance to energy-storage exercise progression that replicates demands of activty limitation

stage IV- return to sport/activity

indication to initiate

• Progressively add training drills then competition when tolerant to full training

• providing load

stage IV- return to sport/activity

dosage

reload: schedule

how many days a week to do isometric exercises?

everyday

how many days a week to do isotonic exercises?

3 days a week, make sure to get rest days

how many days a week to do SSc exercises?

3 - 6 days is good

what shoukd you train to return to activity?

• isometric

• train isotonic

• There is much less evidence specifically related to insertional Achilles tendinopathy Limit stretch and activities requiring full ankle DF

compressive tendinopathy: load progression

Isolated soleus and gastroc during isotonic stage

Loading Specific Tendon Considerations: achilles

• May need to start with open chain and progress to closed chain isotonic exercises

• Add Resistance band around distal tibia during heel raises

Loading Specific Tendon Considerations: Tibialis posterior & fibularii

Initial loading is through stretching then
progress to heel raise with towel roll under
toes

Loading Specific Tendon Considerations: plantar fascia

whats appropriate load?

• NPRS scores vary among patients. identify levels accordingly

• more important: return to baseline within 24 hours

  • if goes away in 24 hours okay but if not then not acceptable

continue working on capacity to limit the chance

prevent

• Adiposity- High BMI

• Cholesterol (Tilley et al., 2015)

• Smoking

• Diabetes (Ranger et al., 2016)

• Rheumatoid arthritis, gout, dyslipidemias, spondyloarthropathies

• Medications: Hormone replacement, contraceptives, Fluoroquinolones,
  Statins (Tilley et al., 2015

Other Pain and Disability Drivers

A Note about Sever’s Disease

• Young athletes (11-13)

• Associated with growth spurts

• Be careful with your language

• Activity modification

• Stretch the gastroc/soleus

• inflammation of calcaenus growth plate

• manage by decreasing pull of gastroc

• increase muscle length there with soft tissues techniques

Calcaneal apophysitis

• Local tenderness, swelling, exertion pain

• X-ray

  • If x-ray (-) and no improvement > MRI

• Relative Energy Deficiency in Sport (RED-S)

• High Risk sites may require period of immobilization and decreased WBing

  • Navicular, 5th metatarsal, hallux sesamoids, medial malleolus, anterior distal tibia

• Treat mobility and movement coordination impairments, EdUReP.

• Bone stress injuries take much longer to resolve vs. acute fracture

A Note about Bone Stress Injuries