Ankle pathologies

Question 1

What are the functions of the foot and ankle?

Answer 1

• provides a stable base necessary for gait
• acts as a shock absorber by providing flexibility

Question 2

What is the functional anatomy of the ankle?

Answer 2

• hinge joint with 1 degree of freedom
• has stability due to both passive and dynamic restraints including: bony articulation (where fibula meets talus), and ligaments
• flexibility provided by complex system of joints and arches, and a dynamic muscular system

Question 3

What are the main pathologies associated with the calf/shin?

Answer 3

• MTSS
• CECS
• Muscle strains

Question 4

What are the main pathologies associated with the heel?

Answer 4

• achilles tendon
• severs disease

Question 5

What are the main pathologies associated with the foot?

Answer 5

• ligament sprains
• plantar fasciopathy
• stress

Question 6

What is a DVT and what do they look like?

Answer 6

deep vein thrombosis - blood clot within a vein

• asymmetrical swelling, heat and pain

Question 7

What is a pulmonary embolism?

Answer 7

DVT blood clot travels to the lungs, blocking the blood flow - managed with anticoagulant therapy

Question 8

How are DVTs caused?

Answer 8

• decreased or mechanically altered blood flow causes blood to become thicker
• changes in the microenvironment then trigger reductions in anticoagulant proteins and increases in procoagulants

Question 9

What is Virchow’s triad?

Answer 9

describes 3 factors that predispose patients to a DVT

• vessel wall injury - damage to the endothelium of the blood vessel
• venous stasis - slowed or stagnant blood flow allows clotting factors to accumulate
• clotting abnormalities - increased tendency of blood to clot, can be inherited or caused by certain diseases eg. cancer

Question 10

What are the Ottawa ankle rules?

Answer 10

An ankle x-ray is required if:
- there is bone tenderness at the posterior edge of the lateral malleolus (6cm up fibula is malleolar zone)
- there is bone tenderness at the posterior edge of the medial malleolus
- inability to bear weight

A foot x-ray is required if:
- there is bone tenderness at the base of the 5th metatarsal
- there is bone tenderness at the navicular
- inability to bear weight

Question 11

What is MTSS and what are the signs?

Answer 11

Medial tibial stress syndrome - pain along the posteromedial border of the tibia that occurs during exercise

• a diffuse painful area on the medial border of the tibia over a length of at least 5cm is highly indicative, pain deteriorates with continued exercise

Question 12

What is the pathology of MTSS?

Answer 12

• contraction of leg muscles creates traction of the tibia surface leading to inflammation of the periosteum

Question 13

How is MTSS caused?

Answer 13

• is an overuse injury related to walking and running activities

associated with increased pronation, plantar flexion and internal/external rotation in the hip, shoes/training surface and hip weakness

Question 14

What are muscle strains and how can they be identified?

Answer 14

tearing of muscle fibres

• soleus strains occur suddenly but are described often as a progressive tightness during activity
• sudden onset with ‘popping’ sensation
• usually localised pain
• may be palpable defects and swelling
• stiffness

Question 15

What is the pathology of muscle strains?

Answer 15

the fibres within the muscle tear with demands placed on them through excessive overload

Question 16

How are gastroc and soleus strains caused?

Answer 16

gastroc tears when the knee is extended and foot is dorsiflexed
soleus - overtraining, sudden increases in load and intense hill running

both associated with muscle weakness

Question 17

How are muscle strains treated?

Answer 17

PEACE AND LOVE, ROM exercises, strength and endurance

Question 18

What is CECS and what is the clinical nugget?

Answer 18

Chronic exertional compartment syndrome - increased compartmental pressure causing reduced blood flow

• symptoms will usually settle within a few mins of stopping activity

Question 19

What is the pathology of CECS?

Answer 19

Increased pressure causes reduced blood flow and reduced tissue perfusion subsequently leading to ischaemic pain and possible permanent damage

Question 20

What are the signs and symptoms of CECS?

Answer 20

• absence of pain at rest
• increasing ache or pain and sensation of tightness with exertion
• muscle tension

Question 21

How is CECS caused?

Answer 21

repetitive overuse followed by inflammation may lead to fibrosis, and therefore reduced elasticity of the fascia surrounding the muscle compartment

Question 22

How can CECS be managed?

Answer 22

• modify activity
• deep pressure massage
• gait interventions
• surgical release may be required

Question 23

What can go wrong with an achilles tendon?

Answer 23

• overuse injury characterised by pain and loss of function (tendinopathy)
• sudden, partial or full thickness tear of tendon fibres (rupture)

Question 24

What are the signs and symptoms of an achilles tendinopathy?

Answer 24

• morning stiffness and pain
• often present at the start of activity and then eases
• palpable nodule may be felt
• swelling

Question 25

What are the signs and symptoms of an achilles tendon rupture?

Answer 25

- positive Thompsons test - palpable deficit present - loss of integrity of tendon

Question 26

What is the pathology of a rupture?

Answer 26

tears of the tendon fibres cause an acute inflammatory response

Question 27

How can an achilles rupture be treated?

Answer 27

- plantar fasciitis boot - surgical repair

Question 28

What is severs disease and what are the symptoms?

Answer 28

- heel pain in growing children it will always settle but may take 6-12 months - activity related pain - localised tenderness of tendoachilles into heel - may cause limp/walking on toes

Question 29

What is the pathology of severs disease?

Answer 29

repetitive micro trauma at the site of attachment of the achilles tendon on the immature calcaneal metaphysis

Question 30

How is severs disease caused?

Answer 30

- usually occurs in active children - associated with tight gastric/soleus and limited dorsiflexion ROM

Question 31

How can severs disease be treated?

Answer 31

- treated as a stress fracture with limited period of partial/non weight bearing and temporary discontinuation of aggravating activity - once pain settles commence calf strengthening

Question 32

What are ligament injuries?

Answer 32

- acute lateral ankle sprains when ligaments are stretched beyond their functional capacity - deltoid ligament can also occur resulting from forced eversion of the foot

Question 33

What is the pathology of ligament injuries?

Answer 33

injury causes an acute inflammatory reaction and laxity

Question 34

What are the signs and symptoms of ligament injuries?

Answer 34

- pain - limping - swelling - bruising - positive anterior drawer and inversion stress - tenderness at anterior talofibular ligament or calcaneofibular ligament (should also be considered based on Ottawa ankle rule findings)

Question 34

How are ligament injuries caused?

Answer 34

- lateral ligaments usually caused by inversion and plantar flexion - greatest risk factor is previous sprain

Question 35

How are ligament injuries managed?

Answer 35

- PEACE AND LOVE - Short period of immobilisation - Gluteal and peroneal strengthening - Balance retraining

Question 36

What is a plantar fasciopathy?

Answer 36

Overuse injury characterised by heel pain and loss of function

Question 37

What is the pathology of plantar fasciopathy?

Answer 37

degenerative fasciosis without inflammation

Question 38

How are plantar fasciopathies caused?

Answer 38

- usually insidious onset secondary to overuse - associated with high BMI

Question 39

How can plantar fasciopathy be managed?

Answer 39

- education and activity modification - stretching and self-mobilisation of fascia - padded footwear - soft tissue techniques

Question 40

What are the signs and symptoms of a plantar fasciopathy?

Answer 40

- tender on anteromedial aspect of the heel - typically worse in mornings - eases with exercise in early stages - painful windlass test

Question 41

What are the risk factors for foot and ankle stress fractures?

Answer 41

- low bone density - muscle weakness - leg length differences - calcium deficiency

Question 42

How can foot and ankle stress fractures be managed?

Answer 42

- requires early and accurate diagnosis - NWB immobilisation with a prolonged period away from sport - may need surgical intervention