Plantar heel pain
When do patients have pain with plantar heel pain?
-pain with loading
-first few steps after inactivity/in the morning
-increases towards end of day
Predisposing factors
Limited DF
Reducted proprioception/functional performance
Decreased hip ABD/ext strength
Other factors: fatigue, age, hx prior injury, reducted strength/endurance/ROM, lower BMI
-level of sport and playing surface irrelevant
What percentage of people with LAS end up with CAI
40%
What is a bone bruise? What would make you worried someone had one after a LAS?
subchondral osseous fracture of the cancellous microarchitecture with accompanied local hemorrhage and edema
*if someone is having a lot of pain with static balance worry about bone bruise (normal static balance after LAS isn't that painful)
*complaints of deep ankle pain that is hard to localize
Achilles tendon rupture:
Initial precautions
Prognosis
Re-rupture rate surgery vs conservative
Precautions: NWB 1st 2 weeks, follow boot rules from doctor, no gastroc/soleus stretching early
Prognosis: 6-9 months for recovery with first 12 weeks in a boot; full RTS 9-12 months
Lower re-rupture with surgery
What kind of orthotic should be recommended?
Off the shelf
-just as good as custom and way less expensive
Ottawa ankle rules
-pain dorsal side of one or both malleoli
-pain at base 5th met
-pain at navicular
-inability to walk at least 4 steps
Define CAI
Episodes of giving way or prolonged instability with activity
Types of sprains that more commonly end up with a bone bruise
Sydesmotic sprains (78%)
Grade III LAS (50%)
**more severe injuries more likely to have bone bruise
History of exercise induced compartment syndrome. Name of surgery?
-pain described as cramping/burning, fullness, tightness during exercise
-predictable onset point during exercise
-pain relieved by rest
-paresthesias
Surgery: fasciotomy or subcutaneous fascial release
Prognosis for plantar heel pain
Chronic/slow to change- symptoms lasting a year +
List Weber classifications
A: below level of syndesmosis (usually transvers, usually stable, deltoid intact, medial malleolus occasionally fx, tibiofibular syndesmosis intact)
B: at level of syndesmosis (usually spiral, syndesmosis usually intact, med malleolus may b fx, deltoid ligt may be torn, variable stability)
C: above level of syndesmosis (widening of tibfib articulation, medial malleolus and deltoid ligt injury common, unstable --> ORIF)
CAI diagnosis criteria (from International Ankle Consortium)
1.History of at least 1 significant ankle sprain
2.Subjective reports of the previously injured ankle “giving way”
3.Episodes of a subsequesnt sprain and/or perceptions of ankle instability
4.Diminished function as measured by the FAAM
5.Confirmation using the Cumberland or IdFAI
How does a bone bruise affect treatment?
How does OCD affect treatment?
Bone bruise: does not change management IF a proper WB progression has been used
OCD: requires 2-4 weeks of NWB
Indications for ankle reconstruction for CAI
Persistent pain and mechanical instability despite 3-6 months of functional rehab
Risk factors for plantar heel pain
-prolonged standing
-footwear (poor shock absorption)
-previous foot injury
-limited ankle DF
-weak calf muscles
-greater age
-increased BMI (in nonathletic ppl)
(altered foot-ankle mechanics)
Examination components for LAS according to CPG. Compare to CAI
-swelling
-talar translation
-SLB
-DF w/ WB lunge test
-SL hopping (when appropriate)
*for CAI: same with examine hip strength
Impairments seen in CAI
-decreased DF ROM
-decreased strength (ankle/knee/hip) ****proximal impairments :)
-abnormal muscle activation timing
-impaired postural control
-impaired ankle proprioception
-altered movement patterns
**impairments can be in involved and uninvolved sides
Lisfranc Injury (aka midfoot sprain)
-MOI
-Categories (2)
-Should you get imaging?
MOI: often high energy (MVA, sport, crush injury, fall/jump/twisting)
*MVA is most common
Categories: low energy (athletic), high energy (trauma)
Imaging is recommended
Type of ankle reconstructions. Which one is the gold standard?
Primary reconstruction =Gold standard (Modified Brostrom-Gould), foot in slight DF and eversion
Secondary Repair/Anatomic Reconstruction: used when ATFL/CFL are too damaged for direct repair, gracilis tendon harvested to repair, uses lots of tunnesl, foot in neutral
Interventions for plantar heel pain recommended in CPG
-manual therapy
-stretching
-taping
-foot orthoses
-night splints
(note foot strengthening not specifically included)
Interventions
Bracing: is good, eventually wean them so only using for high level activity, NOT a stand alone intervention
Compression: gentle is good acutely
Normalize gait: offload as needed, do until have pain free gait w/o compensations
Exercise: NM/proprioceptive, protected ROM (can do end range DF early, avoid PF + inversion), focus on DF, muscle activation, WB as possible *quality over quantity, strength (at ankle and proximal)
Manual: early pain relief (3-6 bouts of 30 sec), later focus on stiffness
Education: timeline, expectations, patient role in recovery
Altered movement patterns in gait with CAI?
Why do we care?
-increased inversion and decreased DF at ground contact
-strategy to keep ankle in close packed position (force attenuation up chain)
Compensatory patterns alter mechanics at ankle and can lead to posttraumatic OA
S/s of Midfoot sprain
Grades (I, II, III)
S/s: midfoot swelling, plantar bruising, pain with TMT joint movement, gentle PF and rotation of forefoot hurts
Grades
I: sprain with no loss of arch height, plantar lifsfranc ligament spared
II: 2-5mm of diastasis w/o collapse of arch height
III: greater than 5mm diastasis, collapse of arch (surgery)
Early precautions for ankle reconstruction?
Prognosis?
Precautions: follow surgeon protocol as these can vary, immobilization and NWB (1-6+ weeks), no ankle inversion/eversion A/Prom for 6 weeks, no INV+PF for 12 weeks, no ankle joint mobs in protective phase
Prognosis: 3 months for running level ground, cutting/jumping 4-6 months
-low revision and reinjury rates, OA rates same for conservative vs non conservative