Achilles Tendinopathy and Rupture
Achilles Tendinopathy
Most common population
Etiology (also intrinsic/extrinsic factors)
Older male athletes who do running activities; running and jumping athletes
Degenerative injury - most often to midportion of tendon, overuse extrinsic and intrinsic factors
-intrinsic (pes cavus, ankle instability, calf mm weakness/tightness, older age, comorbidities, poor tendon vascularity, male etc
-extrinsic: changes in training/loading, hard slanted surface, medications (steroids), footwear, poor technique, previous injury
Most common compartment it happens in? When does it happen most often acutely?
Anterior leg (tends to be unilateral)
Most often happens after a trauma or fracture
MOI for medial ankle sprain
MOI for syndesmotic/high ankle sprain
Medial: eversion (and DF)
Syndesmotic: Direct blow to lateral leg
Externally rotated and DF foot (or everted) with relative IR of leg --> talus acts like a wedge and widens syndesmosis
Where do metatarsal stress fractures most often occur? Who tends to get them?
MOI?
Gold standard?
insidious onset - not a clear MOI
Gold: MRI (SP 100%), xray can miss early changes
What is the most common arthritis of the foot? Who tends to get it most? MOI?
Hallmark sign/what motion is restricted?
Hallux rigidus - most common in people 50 or older, women>men
MOI: tends to be idiopathic, can come from trauma (turf toe, build up of microtraumas)
Hallmark sign = pain, DF of big toe becomes restricted (hard to do anything that requires rolling through forefoot)
Achilles tendinopathy s/s
-pain at beginning and end of activity (warm up period), as gets worse less activity causes pain then pain at rest
-pain after period of inactivity, morning stiffness
-chronic (tender, nodular, swelling)
-acute (diffuse swelling, edema)
S/s: disproportionate pain severity, stiff/wood like feeling, deep ache/burning, paresthesia
Medical emergency --> need fasciotomy within 6 hours, longer it goes more likely to get amputation
Special tests for high ankle sprain?
Gold standard for diagnosis?
Squeeze test, ER stress test, DF lunge test with Compression, tenderness with palpation
Gold: Arthroscopy
How common are shin splints? How to tell if it is a shin splint or a stress fx?
What muscle group is often weak in shin splints?
How often do you see them?
Second most common LE injury (Achilles tendinopathy is 1st)
Pain with shin splint tends to be more diffuse, stress fx more focal
PF tend to be weaker, decreased endurance
1-2 initial visits, then see 1x/month
Treatment for hallux rigidus
First line: PT, foot orthotics
Second line: surgery (joint preserving -cheilectomy or joint sacrificing - fusion))
Tendinopathy intervention and prognosis
Intervention: Load it (heavy slow resistance training, eccentric loading)
Prognosis: variable, recurrence pretty high
in PT about 12 weeks, full RTS 3-6 months
Prognosis following acute compartment syndrome and fasciotomy
Depends on how long it takes to get fasciotomy: before 6 hours very good, over 12 hours increased risk of amputation
Posterior compartment has worse prognosis than anterior
Rehab: usually 12 weeks, may have residual soreness up to a year
what structures do you need to rule out with high ankle sprains
Deltoid ligament involvement (similar MOI's)
Also do ottawa ankle rules to check for fx, fibular fx's, consider bone bruise (common in high ankle sprains)
When do proximal fibular fx tend to happen? Other tissues that can be injured at the same time?
What is the classification system for fibular fx's called?
after and eversion and ER injury of the ankle
Deltoid ligament, AIFTL, interosseous membrane, medial malleoulus fx, proximal tibfib joint
Weber classifications
What is hallux valgus? Who is it most common in/factors that cause?
What muscle is expected to be weak?
Progressive deformity of 1st MTP joint - bunions. More common in women
AKA bunions
Factors: hereditary, tight shoes/heels, first met instability, overpronation, decreased arch in foot, muscle imbalance/other foot conditions, CT disorder (ex RA)
Weak: ABD hallucis
Who is most likely to rupture their achilles? Etiology?
Who: males, 3rd-5th decade, common in sports such as diving, tennis, basketball, track and field, cycling, running, volleyball, gymnastics
Etiology is multifactorial: sudden PF on a DF'ed foot, eccentric load, any foot in extreme pronation or DF is at risk, preexisting tendinopathy, long term steroid/antibiotic use,
high arches, bowlegged, O blood type
S/s of exercise induced compartment syndrome? Agg factors
When should you do your exams?
S/S WITH exercise: nonspecific - fullness, tightness, cramping, paresthesia, weakness, may have bulge/tenderness, pain with passive stretch of compartment
-tends to be bilateral
-at rest usually no s/s
AGG: any repetitive high intensity movement (running, cycling etc)
a physical exam should be done pre- and immediately post-
exercise.
Common activities to injury the deltoid ligament
running down stairs, landing on uneven surfaces, dancing, contact sports
What is a jone's fracture? Why are they bad sometimes?
Prognosis conservative, surgery?
Fx at base of 5th metatarsal , poor blood supply leading to poor healing and nonunion
Conservative: 6-8 weeks
Surgery: 4-6 months for RTS, can be as fast as 2-3 months
Treatment for hallux valgus
Prognosis
Patient education: shoes (lower heels, wide toebox), toe spacers, orthotics, night splints, bunion pads are all options
Manual
exercise
Prognosis : 1-2 visits then check in in a few weeks, if have surgery see them for 4-6 weeks (6-12 wks for full return to work)
Prognosis: non operative achilles rupture management
-may be slower return than operative, higher rerupture rate (is controversial which is better)
-rehab 3-6 months for non athletes
-RTS: 6months-1year (most people are able to return)
Differential diagnosis for exercise induced compartment syndrome
Gold standard for dx
-shin splints
-tibial stress fracture
-tendon pathologies
-nerve entrapment
-vascular (ex intermittent claudication)
Gold standard:
Intracompartmental pressure (ICP) measurements before, during, and after exercise, postexercise is the best measure.
*increased pressure does not directly correlate with increased pain
Bonus: morton's neuroma
-what nerve is affected, s/s, what can cause it
intermetatarsal plantar digital nerve is squished by the transverse intermetatarsal ligament (repetitive trauma, heels, crush injury, penetrating injury)
s/s: localized/sharp pain, burning/tingling b/w toes, numbness
Who is most likely to get got? What causes it? Symptoms?
men over 30, male>female
Caused by build up of uric acid crystals in foot. Pain and swelling in joint (most often in big toe but can happen in any joint). Flares are self limited lasting up to 3-4wks.
There are 4 stages: asymptomatic, acute gouty attack, remission and chronic tophaceus gout
*chronic is bad bc can cause permanent joint damage