F/A examination

parts of the regional trauma screen

Ottawa ankle and foot rules

fracture auscultation test

how Sn is the ottawa ankle rules for XR

98%

how Sp is the ottawa ankle rules for XR

40%

What are the ottawa ankle rules

Malleolar pain and any of the following are present:

• bone tenderness at the posterior edge (distal 6 cm) or tip of lateral malleolus

• bone tenderness at the posterior edge (distal 6 cm) or tip of medial malleolus

• inability to WB both immediately and in the ED

What should you do if there is too much swelling to palpate the malleolar bone

• palp the entire distal 6 cm of fibula and tibia

• do not neglect importance of medial malleolar tenderness

• WB counts even if patient limps

• patients under 18 may not react appropriately

how Sn is the ottawa foot rules for XR

99%

how Sp is the ottawa foot rules for XR

38%

What are the ottawa foot rules

pain in midfoot zone and any of the following:

• bone tenderness at the base of the 5th MT

• bone tenderness at the navicular bone

• inability to WB both immediately and in ED for 4 steps

positive on ottawa or fx auscultation indicates what action

refer for XR at ortho urgent care

immobilize

negative on ottawa or fx auscultation indicates what action

local exam

What self reported outcome measure if used for F/A

foot and ankle ability measure (FAAM)

soring scale for FAAM Qs

4-0 (no difficulty - unable to perform)

MDC on FAAM for ADLS

6

MDC on FAAM for sports

12

MCID on FAAM

8-9

Should you recommend ankle braces for preventing first ankle sprain

yes - grade A

Should you recommend braces after an ankle sprain

yes, w/ balance therex - grade A

cluster for acute lateral ankle sprains

• reverse antlat drawer test

• antlat talar palp

• anterior drawer test

• thorough hx and physical examination

describe grade 1 sprain

stretching, small tears

describe grade 2 sprain

larger, but incomplete tear

describe grade 3 sprain

complete tear

procedure for anterior drawer test

• supine or sitting

• 20 degrees PF

• stabilize tibia and draw talus ant

  • + excessive translation

procedure for talar tilt test

• supine, sitting, sidelying

• foot in DF

• inversion stress added by adducting rearfoot

  • + increased laxity

procedure for reverse antlat drawer teat

• 10-15 degrees PF

• foot rested on the table

• posterior glide of tibia

  • + increased laxity, clunk

prevalence of syndesmosis injury out of ankle sprains

~10%

presentation of a syndesmosis injury

DF w/ ER

cutting sports (w/ cleats)

delayed ecchymosis

another name for syndesmosis injury

high ankle sprain

special tests for high ankle sprain

DF ER stress test

syndesmosis squeeze test

other name for DF ER stress test

Kleiger’s test

procedure for DF ER stress test

• supine or sitting

• passive DF and ER

  • + pain in area of syndesmosis or over interosseus membrane

procedure for syndesmosis squeeze test

• sitting, supine, prone

• fib and tib compressed midway up calf

  • +pain in area of syndesmosis

What is the syndesmosis

interosseus membrane between tibia and fibula

presentation of ankle sprain

• swelling

• ROM

• talar translation, talar inversion

• SL balance

procedure for figure 8 edema measuring

midway between tib ant and lateral mall → meddially to distal navicular tub → across to prox 5th met → cross tib ant around ankle just distal to med mal → over achilles to start

Therex recommendations for lateral ankle sprains

• protected AROM

• stretching

• neuromuscular

• training

• postural re-education

• balance training

is manual therapy beneficial for ankle sprains

unclear

What are ankle sprains commonly lead to

decreased DF ROM

goals of therex for chronic ankle instab (CAI)

proprioceptice and neuromuscular

should manual therapy be used for CAI

yes

what balance strategies do we have

ankle

knee

hip

lumbar

What kind of ankle balance exercises should we perform

stable surfaces

What is the best balance training after LE injury

moving through the postures (EO and EC) to rest compensatory strategies

What should be tested during strength testing

ankle and hip strength

describe boney ankle impingement

ant med (DF) and post lat (PF)

describe soft tissue ankle impingement

ant lat (bassett’s lig) and post med

treatment for impingement

possible arthroscopic debridement

examples of impingement

os trigonum and FHL

cause of anterior ankle impingement

spurring on lip of talus or neck of talus

cause of anterior-lateral ankle impingement

build up of synovitis and/or scar tissue secondary to trauma

cause of posterior ankle impingement

Os trigonum

describe os trigonum

tenderness in the post lat aspect of ankle due to an accessory bone or sprain in PF

describe sinus tarsus syndrome

pain deep in sinus tarsus

worse w/ impact and pronation

cause of sinus tarsus

osteophytes

nerve entrapment

soft tissue impingement

treatment for overuse/misuse dxs

address our load issues

is being a pronator/supinator bad?

not necessarily

arch type for supinator

high arch (pes cavus)

arch type for pronator

flatfoot (pes planus)

What was the idea that lead to the myth about foot alignment

optimal foot position is the exact alignment of tibia, talus, and calc

purpose of pronation during gait

shock attenuation and terrain adaptation

Triplanar motion of pronation

ankle DF

STJ EV

midfoot abd`

pronation affect of the tibia

IR

affects if pronation of LE length

shortens limb

lengthens foot

What position leaves the ankle unstable

pronation

What is normal subtalar mvmt

supination at heel strike

pronation at foot flat

resupination at heel off

purpose of resupination during gait

activate windlass mechanism

How can excessive pronation be bad during gait

overload stabilization elements → overuse injuries

describe the windlass mechanism

1. big toe ext

2. shortening of plantar fascia

3. elevation of medial longitudinal arch

4. ready for push off

how is navicular drop recorded

1. mark the navicular tubercle

2. place ankle in subtalar neutral

3. measure distance of mark to the floor

4. repeat measurement in half squat and SL squat

5. record the amount of drop

Normal navicular drop

5-9 mm

What is a supinated foot for navicular drop

<5 mm

What is a pronated foot for navicular drop

>9 mm

how is DF and pronation related

lack of DF ROM may result in a compensation of toe-out walking in order to use pronation to gain the extra degrees of ankle ROM

What is the difference between tendinitis and tendinosis

length of patho

• itis - acute, <6 weeks

  • osis - chronic

What is the ideal recovery time for tendons

36-72 hrs

what factors affect recovery

poor sleep

nutrition

hydration

What does the research say about therex for tendinopathies

eccentrics are best, however may be too painful and should start w/ isometrics

What type of exercise provides an analgesic effect

isometrics

What should you progress to if eccentrics are not yet tolerated

concentric

effects of complete rest, NSAIDs, and corticosteroid injections

not recommended due to further degradation of tissue

Where is insertional achilles tendinopathy

at the calc (insertion site)

Where is non-insertional achilles tendinopathy

midportion (2-6 cm above insertion)

describe peritendonitis

limited to peritenon censervative

describe peritendinitis w/ tendinosis

focal degeneration, partieal tears, at risk for rupture

What is Alfredson Protocol

calve raises

3×15 reps

2x/day

12 wks

bent and straight knee

What is problematic about Alfredson Protocol

not enough time for recovery

What does new evidence suggest for frequency of tendon exercise interventions

3x/wk

What is the flow for tendinopathy therex progression

What is not indicated for tendinopathy interventions

• complete rest

• manual therapy

• dry needling

• orthoses

• lasers

• US

What is a way we can help patients reduce achilles tendinopathy pain acutely

heel lifts

other name for insertional tendinopathy

retro-calcaneal bursitis

Haglund deformity

describe haglund deformity

chronic irritation results in chemical erosion/Ca formation

treatment for insertional tendinopathy

modified alfredson protocol (not lower than neutral)

test for achilles tendon rupture

Thompson

Matles

procedure for thompson

squeeze calf in prone w/ feet off end of table

procedure for Matles

squeeze calf in prone w/ knees at 90

prevalence of plantar fasciopathy

1/10 report at some point in lifetime

When is plantar fasciopathy most common

45-65 y/o

risk factors for plantar fasciopathy

lim DF

increased BMI

standing for prolonged periods

presentation of plantar fasciopathy

• sharp pain w/ first steps in morning or after long period of rest

• irritated w/ prolonged WB

• TTP at plantar fascia insertion

Should foot orthoses be used for plantar fasciopathy treatment

not as an isolated treatment