Ankle-Foot Injury Injuries

Transcription

1 Ankle-Foot Injury Injuries Ed Mulligan, PT, DPT, OCS, SCS, ATC Clinical Orthopedic Rehabilitation Education What are the possible imposters to orthopedic foot/ankle injuries? 1. Lumbar Radiculopathy 2. Vascular Claudification (PAD Intermittent Claudication) 3. Neurogenic Claudication (Spinal Stenosis) 4. Diabetic Neuropathy 5. Restless Leg Syndrome 6. DVT 7. Avascular Osteonecrosis 8. Vascular Entrapment Leg Injuries Shin Splints Geographic diagnosis suggesting orthopedic pathology somewhere between the knee and ankle Differential Diagnosis Medial Shin Pain Posteromedial shin pain due to overuse can indicate inflammatory microtrauma to the tendon of the posterior tibialis Periosteal irritation and tibial stress reactions may also be suspected medial tibial stress syndrome medial tibial stress is the result of abnormal hyperpronation biomechanics muscles in the deep posterior compartment contract in a stretched position and are overworked in an attempt to stabilize the foot during propulsion

2 predisposing factors improper training on crowned or banked surfaces inappropriate footwear any structural condition that increases the varus attitude of the lower extremity posterior tibialis tendinitis S/S Pain swelling present over the posteromedial crest of the tibia along the its origin Tenderness and crepitation found anywhere along the course of the tendon as it passes behind the medial malleolus and inserts distally on the navicular and 1 st cuneiform posterior tibialis tendinitis exam findings Manual resistance to plantarflexion inversion localizes the complaint In subacute phases, repeated unilateral heel raises, which require plantar flexion and supination of the calcaneus, can be a source of symptom aggravation posterior tibialis tendinitis treatment alleviating abnormal pronation semirigid orthotic with a medial heel wedge training i and dadl education eccentric exercise progression shoes with a stable, firm, and snug heel counter Kulig K, et al, Phys Ther, 2008 Kulig K, et al, Foot Ankl Int, 2009 Flexor Hallucis Tendinitis Repetitive push off maneuvers Ballet dancers Divers Rope jumpers Management Ideas - Varus posting if hyperpronation - Tape restriction of 1 st MTP df - Stiff midsole - NSAIDs tennis leg musculotendinous lesion of the medial gastrocnemius head (not a plantaris rupture) MOI sudden extension of the knee with the foot in a dorsiflexed position. Predisposition middle aged athletes or those with previous degenerative changes in this area

3 tennis leg signs and symptoms sudden, sharp twinge in the upper medial calf immediate difficulty in full weight bearing rapid swelling and ecchymosis point tenderness or a palpable defect at the site of the lesion tennis leg management Acute Care ice, compression, and elevation ankle is placed in mild plantar flexion to alleviate stress on the area of injury NWB crutch gait may be necessary, depending on the severity of the injury Subacute Care Gradual, gentle static stretching Friction massage heel lifts used in the shoe to protect against weight bearing stresses Anterior Compartment Syndrome Anterior Compartment Syndrome Signs/Symptoms Contusions, crush injuries, fractures, or severe overexertion can cause a rapid increase in compartmental volume from bleeding or muscular swelling Increased intercompartmental pressure leads to venous collapse and increased resistance to arterial circulation These physiologic changes produce an ischemic pain complaint and, ultimately, tissue necrosis if the process is left uninterrupted Chief complaint is intense pain disproportionate to the injury that is not relieved by rest Palpation reveals a ``woody tension'' over the muscles of the anterior compartment Passive plantar flexion evokes pain In the advanced stages, neurologic changes may be evident, and the dorsalis pedis and anterior tibial pulses may be diminished Anterior Compartment Syndrome Management Exertional Compartment Syndrome This condition is considered a medical emergency, because early muscle damage occurs in the first 4 to 6 hours and irreversible tissue damage occurs within 18 hours after injury Acute care consists of ice application without compression and monitoring of the neurovascular status If pain and swelling do not respond to conservative treatment, an emergency surgical fasciotomy must be performed same pathophysiology as acute compartment syndrome, but its presentation and care are different Complaint of lower leg pain and tightness that occurs at a constant interval following the initiation of physical activity Symptoms subside with rest but return on resumption of the activity Most patients have bilateral involvement with mild edema, tenderness, and occasional paresthesia Diagnosis is confirmed with wick catheter measurement of intercompartmental pressure at rest and during activity A pre exercise pressure of 15 mmhg A 1 minute post exercise pressure of 30 mmhg A 5 minute post exercise pressure of 20 mmhg

4 Management of Exertional Compartment Syndrome Foot Injuries ice application before and after exercise lower leg stretching balancing of plantar flexion dorsiflexion strength alterations in the training program to decrease muscular workloads beveled heel shoes softer training surfaces energy absorbing orthotics tarsometatarsal sprains, dislocations and fractures LisFranc s Joint Direct mechanism crushing type of injury Indirect mechanism injuries usually occur with an axial load to the heel with the foot in plantarflexion causing a hyperextension stress on the the joint Pain with passive pronation supination and palpation tenderness pain and/or inability to perform unilateral heel raises, jumps, or cutting maneuvers tarsometatarsal sprains, dislocations and fractures LisFranc s Joint Mild swelling tarsometatarsal sprains, dislocations and fractures LisFranc s Joint foot is immobilized dependent upon the severity of the injury Rehabilitation and weight bearing progression can commence following immobilization with a gradual progression of functional activities on the toes Medial midfoot sprains tend to progress at a slower rate and take longer to return to full activity cuboid syndrome partial displacement of the cuboid bone by the pull of the peroneus longus Mechanism of Injury onset can be gradual or traumatic trauma or with a powerful contraction, with the foot in a plantar flexed and inverted position gradual onset is more typical in the hyperpronated foot the peroneus longus is at a mechanical disadvantage, and it pulls the lateral portion of the cuboid dorsally and the medial portion in a plantar direction

5 cuboid syndrome Signs and Symptoms decreased or abnormal accessory motion of the calcaneocuboid joint tenderness along the cuboid, peroneus longus, and lateral met heads cuboid syndrome Treatment directed at restoring normal osteokinematics and protecting against further trauma or aggravation ice massage or a cold whirlpool bath bony manipulation dorsal thrust low dye taping or medial heel wedges can be used to counteract the damaging pull of the peroneus longus 5th proximal metatarsal diaphyseal fracture Weight bearing forces are great on the 5th metatarsal because of its many soft tissue attachments Tension on the bone from the peroneus brevis, cubo metatarsal ligament, lateral band of the plantar fascia, and peroneus tertius can lead to stress reactions, which can become a complete fracture with inversion trauma or a nonunion stress fracture with repetitive forces Fracture is just distal to the base of the 5 th metatarsal and is notoriously unpredictable in its healing Nonunion and reinjury are frequent 5th proximal metatarsal diaphyseal fracture Management is controversial screw fixation across the fracture site vs. nonweight bearing immobilization screw fixation method has shown predictable healing with return to full athletic competition in about 8 wks Conservative management 4 to 6 weeks of healing; the cast is then removed to determine whether the athlete can function with a nonfibrous union. Full athletic participation is contraindicated until fracture site consolidates. When healing is complete, orthotic therapy should be considered to redistribute injurious forces Posterior Heel Pain os trigonum Mechanism Injury is common in athletes who function on their toes (e.g., ballet dancers) or who encounter resistance to dorsiflexion while in the extreme of plantar flexion (e.g., soccer player having a kick blocked) Symptoms Accessory bone fracture or soft tissue pinching produces severe local pain in the posterolateral portion of the ankle

6 os trigonum Conservative treatment involves taping techniques to limit end range plantar flexion If this motion is necessary for performance, surgical excision may be necessary retrocalcaneal bursitis long distance running and repetitive jumping can create a bursal inflammation between the Achilles tendon and calcaneus condition aggravated by excessive compensatory pronation, which results in cumulative trauma and pressure to the posterolateral aspect of the heel structural predisposition to bursal inflammation may exist in the cavus foot if there is spurring on the posterior superior aspect of the calcaneus retrocalcaneal bursitis SIGN/SYMPTOMS characterized by pain, swelling, and discoloration on the posterolateral and superior aspects of the heel tenderness is elicited anterior to the Achilles tendon but posterior to the talus retrocalcaneal bursitis TREATMENT Ice, NSAIDs, and orthotic control of the hypermobile calcaneus Heel counter collar modification Shoe selection should place a high priority on a stable heel counter Structural predisposition may be alleviated by a heel lift, or surgical excision of bony spurs in chronic conditions that do not respond to conservative management may be necessary. sever s disease traction epiphyseal injury in active adolescents DESCRIPTION tight Achilles tendon pulls on the calcaneal epiphyseal attachment producing a disruption of circulation and possible fragmentation common with cleated shoe wears or rapid alterations in the heel height of the athletic shoe sever s disease traction epiphyseal injury in active adolescents SIGNS/SYMPTOMS young athlete pain on the posterior heel at the insertion of the Achilles tendon aggravated by activity and relieved by rest condition ends at skeletal maturity when the epiphysis closes TREATMENT judicious rest and the insertion of bilateral heel lifts to alleviate injurious stresses

7 Digit Injuries morton s neuroma burning or electrical shock sensation in the forefoot that radiates into the toes lesion usually between 3 4th met heads pain alleviated with shoe removal and increased or reproduced with compression of met heads hallux valgus metatarsal stress fractures Definition abductovalgus at 1st MTP Symptoms painful 1st MTPJ with swollen bump on side of foot Treatment Shoes: avoid pointed shoes, use of inflare bunion lasts, stretch or cut shoe over bunion, and Thomas heel Orthotics: control STJ/MTJ pronation Stress fracture of the 3rd metatarsal. Note the periosteal reaction (white circle) at the site of a stress fracture Osteoclastic activity > osteoblastic activity due to prolonged hyperpronation and excessive mobility of the 1st ray predisposition greatest in FF varus and decreased ankle joint dorsiflexion most common at beginning of season or deconditioned or overtrained athlete metatarsal stress fractures morton s neuroma treatment Signs/Symptoms Localized pain and swelling pain increased with activity and decreased with rest exacerbated by percussion or AROM Treatment rest; activity modification; NWB; alternative training orthotic relief and/or taping correction of soft tissue imbalances or biomechanical predisposers met pad placed just proximal to 3rd and 4th met heads to redistribute weight bearing forces and increase spatial spread shoe with wide toe box orthotic control of hyperpronation corticosteroid injection surgical excision if symptoms persist and become disabling

8 turf toe turf toe predisposing factors acute hyperdorsiflexion injury to the first MTP joint as the toes are pressed down into an unyielding surface just prior to toe off force causes hyperextension of the MTP joint as the phalanx is jammed into the metatarsal repetitive trauma of this nature results in plantar capsule tears, articular cartilage damage, and possible fracture of the medial sesamoid bone chronic trauma can lead to metatarsalgia, with ligamentous calcification and hallux rigidus Sudden acceleration under high loads against unyielding surface (e.g. astroturf) Hyperflexible shoes that offer minimal support increase risk of injury Increased shoe length can lengthen the lever arm forces acting on the joint, and the feet are subject to repetitive trauma turf toe S/S and treatment tender, red, and swollen first MTP joint that has increased pain with passive toe extension rest, ice, compression, elevation, and support to the injured joint tape immobilization to check excessive extension and valgus stresses rehab procedures may include ultrasound to mobilize scar tissue formation, and AROM exercises with the first ray stabilized turf toe subacute rehabilitation gentle dorsal glides of the first phalanx to improve arthrokinematic mobility steel spring plate in the toe box or rigid taping into plantarflexion should be used initially when resuming full participation On return to activity, the athlete should possess at least 90 of painless passive toe extension and have been screened for appropriate shoe selection sesamoiditis two small sesamoid bones of the foot on the plantar surface of the 1 st methead, embedded within the tendon of the flexor hallicus brevis sesamoid bones function to enhance the windlass mechanism and help distribute and disperse weight bearing forces during propulsion The medial or tibial sesamoid is often bipartate, and its appearance can be confused with a fracture sesamoiditis predisposing factors rigid cavus foot tight Achilles tendon plantar flexed first ray activities that require maximal dorsiflexoin of the 1 st MTP joint allows excessive impact loading stresses on the sesamoids pressure from improper cleat placement on the athletic shoe may also be a source of further aggravation

9 sesamoiditis S/S and treatment hammer toes Signs/Symptoms tenderness and swelling of the first metatarsal head pain with passive dorsiflexion Treatment ice massage, NSAIDs or cortisone injections, and rest. pulsed phonophoresis and iontophoresis are alternative methods of combating the inflammatory response definitive treatment must include relief of weight bearing stresses on the affected area semirigid orthotic with the first ray cut out, dancer s pad or a Morton's extension with sesamoid dimple can provide this relief Definition: Hyperextension at MPJ, flexion at PIP, and hyperextension at DIP joint Symptoms: gradually increasing pain over dorsum of toes Treatment: Metatarsal pad if PIP joint can be extended with manual pressure on the met head Mobilization prn intrinsic musculature strengthening hallux limitus/rigidus Osteophytes impinge and limit df ROM pes cavus Definition: inflexibility of 1st MTP into extension Symptoms pain during propulsive phase of gait. foot pain from repeated attempts to avoid stress on the great toe walk on the outside part of the foot to avoid pain Treatment Mobilization for limitus; 1st metatarsal head cut out, morton s extension, and/or steel spring plate in forefoot. Shoe modifications include stiff forefoot or rocker bottom sole Definition: structural high arch; often associated with neuromuscular disease Symptoms: painful midtarsal joints and pain under met heads due to high metatarsal inclination Treatment: Custom shoes with extra toe box depth Shock absorbing insoles pes planus Definition structural low arch Symptoms early fatigue of muscles with activity Susceptible to many injuries associated with hyperpronation Treatment Orthotics anterior/posterior tib and peroneal strengthening