Stanbridge - T4 - TE2 - W5 - The Foot & Ankle

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Questions and Answers

Which joint is primarily involved in the posterior glide of the talus during dorsiflexion?

Transverse tarsal joint

Talocrural joint (correct)

Talo-navicular joint

Calcaneofibular joint

What movement characterizes the tri-planar motion of supination?

Pronation and adduction

Plantarflexion and inversion (correct)

Dorsiflexion and eversion

Abduction and extension

Which of the following is NOT a common cause of joint hypomobility?

Herniated disc (correct)

Arthritis

Gout

Post-immobilization

What is the main purpose of aquatic therapy in the management of joint hypomobility?

To facilitate pain-free movement and exercise Signup and view all the answers

Which ligaments support the lateral aspects of the talocrural joint?

Anterior talo-fibular ligament Signup and view all the answers

How are the phases of recovery after an inflammatory insult to the ankle and foot characterized?

Gradual increase in ROM and activity modification Signup and view all the answers

In the context of managing soft tissue lesions in the ankle, what does daily PROM refer to?

Passive range of motion exercises Signup and view all the answers

What is a key focus of the strength training program during the late subacute phase?

Strengthening the entire lower quarter and core stability Signup and view all the answers

Which type of training is emphasized to address proprioceptive deficits in the late subacute phase?

Unstable surface balance training with visual aids Signup and view all the answers

Which of the following is NOT a component of manual therapy during the acute phase?

Cold pack therapy Signup and view all the answers

What type of exercises are recommended to start in the early subacute phase?

Joint mobilization and ROM exercises progressing from sagital to multi-planar motion Signup and view all the answers

During the chronic phase of rehabilitation post-ankle sprain, what is the primary goal of the training program?

Incorporate sport or skill-specific exercise for a safe return to sport Signup and view all the answers

What is the primary indication for Total Ankle Arthroplasty (TAA)?

Severe, persistent pain during weight-bearing, compromising function Signup and view all the answers

What type of exercises are recommended in the moderate protection phase post-TAA?

Low intensity high repetition open and closed chain exercises Signup and view all the answers

Which of the following is NOT a treatment option in the acute phase of ankle hypomobility?

Strengthening exercises Signup and view all the answers

What is a key management strategy for arthrodesis of the ankle?

Do not stretch what is fused Signup and view all the answers

What is the primary purpose of mobilization with movement (MWM)?

To enhance range of motion both in dorsiflexion and plantarflexion Signup and view all the answers

What should be a primary focus during the maximum protection phase after TAA?

Preventing stiffness and minimizing muscle atrophy Signup and view all the answers

Which condition is most likely to require arthrodesis as a management strategy?

Late-stage arthritis causing debilitating pain Signup and view all the answers

In the context of joint surgery, what condition is characterized by severe pain while weight-bearing?

Post-traumatic degenerative joint disease Signup and view all the answers

What is a common treatment focus in the chronic phase of managing joint hypomobility?

Strengthening and endurance exercises Signup and view all the answers

What is the most common cause of shin splints?

Poor pre-season conditioning Signup and view all the answers

Which muscle is primarily involved in anterior tibial stress syndrome?

Anterior tibialis Signup and view all the answers

What conservative treatment is advised for shin splints?

Change activities to avoid overuse Signup and view all the answers

Which of the following best describes chronic ankle instability (CAI)?

Occurs in 10-20% of individuals post-acute sprain Signup and view all the answers

What anatomical position is commonly associated with a lateral ankle sprain?

Plantarflexion with Inversion Signup and view all the answers

What rehabilitation issue is commonly overlooked that can lead to further ankle injuries?

Underestimating the severity of the injury Signup and view all the answers

Which of the following is NOT a common symptom of shin splints?

Swelling in the ankle joint Signup and view all the answers

What strategy is least effective in managing shin splints?

Engaging in high-impact exercises immediately Signup and view all the answers

Which factor is least likely to contribute to shin splints?

A high level of pre-season conditioning Signup and view all the answers

What is a common rehabilitation goal after an ankle sprain?

Preventing chronic conditions Signup and view all the answers

Which of the following factors can contribute to the overload of the posterior tibialis tendon?

Increased activity levels Signup and view all the answers

What is a common clinical finding associated with posterior tibialis tendinopathy?

Visible swelling along the tendon Signup and view all the answers

Which treatment approach is advisable for managing posterior tibialis tendinopathy?

Eccentric loading exercises Signup and view all the answers

During a clinical assessment, which activity might indicate an issue with the posterior tibialis tendon?

Pain or inability to complete a single leg heel raise Signup and view all the answers

Which aspect of the posterior tibialis muscle is critical in controlling pronation?

Eccentric contraction Signup and view all the answers

In the treatment of posterior tibialis tendinopathy, what should be initially avoided?

Strengthening into maximal plantar flexion Signup and view all the answers

Which of the following is NOT a recommended clinical test for posterior tibialis tendinopathy?

Palpation of the anterior tibialis Signup and view all the answers

Which training factor is most likely to lead to posterior tibialis tendinopathy?

Sudden increase in running speed Signup and view all the answers

Which treatment principle should be emphasized for individuals with limited endurance of the plantar flexors?

Initiating load management Signup and view all the answers

Which of the following best describes a risk factor for developing posterior tibialis tendinopathy?

Wearing stylish but unsupportive shoes Signup and view all the answers

Study Notes

Therapeutic Exercise II: The Ankle and Foot

This presentation covers the anatomy, function, and treatment of ankle and foot injuries and conditions.
Identifying aspects of structure and function for review is one of the learning objectives.
Implementing a therapeutic exercise program to manage soft tissue and joint issues is also a learning objective.
The presentation further discusses the advantages and disadvantages of arthroplasty versus arthrodesis for patients with rheumatoid arthritis (RA).
Developing and enhancing ROM are other learning objectives.
The topic will cover various aspects, such as anatomy and arthrokinematics, ankle hypomobility, tendinopathies, shin splints, and ligamentous injuries.
Different types of joint hypomobility conditions are rheumatoid arthritis (RA), Juvenile RA, osteoarthritis (OA)/deformative joint disease (DJD), trauma, post-dislocation joint reactions, fractures, and post-immobilization.
It will also cover the management of conditions causing joint hypomobility.
Common impairments during joint hypomobility include decreases in joint play, pain, swelling, restricted motion, muscle imbalance, weakness, decreased endurance, impaired balance, postural control, frequent falling, and painful weight bearing/gait deviations.
Management of joint hypomobility will include educating patients on home exercise programs (HEP), activity modifications, gait training, range-of-motion (ROM) exercises, bracing, orthotics, assistive devices, grade 1/2 joint mobilization, and aquatic therapy/muscle setting.
The presentation describes the bones of the ankle and foot—posterior, medial, and lateral views including bones such as tibia, fibula, talus, navicular, cuneiform, and calcaneus.
The hindfoot consists of the talus and calcaneus.
The midfoot consists of navicular, cuboid, and three cuneiforms.
The forefoot comprises five metatarsals and 14 phalanges.
Tibio-fibular joints (superior and inferior) are included in the discussion, offering accessory motions and forming the proximal talocrural joint.
The talocrural joint is supported laterally by the lateral collateral ligament (consisting of the anterior talofibular, posterior talofibular, and calcaneofibular ligaments).
The joint is also supported medially by the deltoid ligament.
Arthrokinematics are key, with dorsiflexion causing posterior glide and plantarflexion causing anterior glide of the talus.
Functional anatomy involves tri-planar motions (supination and pronation).
Supination consists of plantarflexion, calcaneal inversion, and forefoot adduction, maintaining stability and arch height in weight bearing.
Pronation includes dorsiflexion, calcaneal eversion, and forefoot abduction; unlocking the midfoot for shock absorption.
The transverse tarsal joint (talo-navicular and calcaneo-cuboid joints) participates in supination/pronation midfoot movement-abduction, adduction, inversion, eversion, and dorsal/plantar gliding.

Joint Surgery and Postoperative Management

Total ankle replacement arthroplasty (TAA) is a surgical option.
Indications for TAA include disabling pain during weight bearing (WB), post-traumatic arthritis (DJD), osteoarthritis (OA), rheumatoid arthritis (RA), avascular necrosis (AVN) of the talus, inflexible deformity, and prior conservative care failures.
Arthrodesis, a fusion of the ankle and foot joints, is another surgical procedure often used for late-stage arthritis, marked instability, high functional demands during weight bearing (WB), and failed TAA.

Overuse (Repetitive Trauma) Syndromes: Non-Operative Management

Overuse syndromes encompass various pathologies, etiologies, conditions, impairments, functional limitations, and disabilities.
The management approach for overuse syndromes focuses on distinct phases—acute, subacute, and chronic—with specific interventions for each phase.

Tendinitis vs. Tendonosis

The distinction between tendinitis (inflammation) and tendonosis (degenerative changes) is crucial in diagnosis.
Tendinitis typically involves sharp pain with activity, worsening with rest, and improved with activity and rest.
Tendonosis is characterized by dull pain, worsening with activity, in the absence of significant inflammation and often shows palpable enlargement.

Plantar Fasciitis

Plantar fascia provides arch support and assists in gait initiation.
Corticosteroid injections are often ineffective and may cause atrophy and fascial rupture; histological studies reveal a lack of inflammation.
Lower longitudinal arch height, high loading rates, and high arch foot (pes cavus) are potential predisposing factors.
Symptoms often include sharp heel pain, worse in the morning or after periods of rest, and decreasing after warming up, worsening with weight-bearing.

Achilles Tendinopathy

The Achilles tendon, the largest and strongest tendon in the body, plays a significant role during weight bearing, decelerating ankle dorsiflexion and subtalar pronation.
Factors influencing the development of Achilles tendinopathy include overuse, training errors, faulty equipment, improper recovery, and repetitive training.
Microscopic anatomy reveals continuous fibers with the plantar fascia.
The hypovascular zone (approximately 5-6 cm above the insertion site on the calcaneus) is susceptible to degenerative changes.
Conservative treatment is often effective.

Posterior Tibialis Tendinopathy

Posterior tibialis plays a major role in controlling ankle pronation.
Overuse from increased activity, frequent running, speed, weight, or poor footwear can lead to overload and inflammation.

Ligamentous Injuries (Nonoperative):

Assessing and managing impairments and functional limitations in ligamentous injuries, focusing on the acute, subacute, and chronic phases of healing is important.
Typical lateral ankle sprain occurs from plantarflexion and inversion.

Ankle Sprain:

Radiographs to exclude fractures are important in an acute phase.
Support (like bracing and casting) and physical therapy help address pain and swelling.

Chronic Ankle Instability (CAI):

Occurs in 10-20% of patients following acute ankle sprains.
Characterized by persistent and recurrent pain, swelling, and instability for over six months.
Often involves a "giving way" sensation (neuromuscular deficit) in 17-58% of patients.

Neuromuscular Changes Following Ankle Sprain:

Proprioception, neuromuscular control, muscle inhibition, and reaction times negatively affected.
Reduced strength and altered muscle sequencing.
Impaired postural control and altered lower limb movement patterns.

Goals of Neuromuscular Training:

Optimizing lower limb postural control and stability.
Preventing chronic ankle instability.
Enabling safe return to sport or activity.

Phases of Rehabilitation:

Acute phase, early subacute phase, late subacute phase, and chronic phase (including return to sport).

Acute Phase: Goals, Treatment and Considerations

The first step in treating ankle sprains or other acute injuries involves steps to protect the joint, promote healing, and reduce inflammation/pain.
Techniques used during the acute phase include rest, immobilization, ice application, pain relief medication (NSAIDS), compression and elevation

Early Subacute Phase:

ROM exercises, balance training, strength training, and functional training should be implemented during the early subacute phase to facilitate a safe and effective recovery.

Late Subacute Phase:

Strengthening and balance exercises targeted toward neuromuscular integration and promoting proper ankle joint stability and control.

Chronic Phase (Return to Sport):

Comprehensive training programs to reintegrate the injured ankle into the specific demands of the sport are emphasized.

Ankle Sprain: Evidence

This section covers the evidence-based diagnosis and treatment of ankle sprains, including the use of the Ottawa Ankle Rules, risk factors, and evidence-based treatment strategies.

Exercises for the Foot & Ankle:

Various exercises, such as flexibility and strengthening exercises, are presented (e.g., gastrocnemius stretch, resisted ankle dorsiflexion, inversion and eversion exercises, calf strengthening exercises, balance exercises, and others).

Review Summaries:

Reviews of specific conditions (shin splints, plantar fasciitis, and achilles tendinitis) are provided along with their typical presentations and treatment strategies.

Studying That Suits You

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Description

Test your knowledge on key concepts related to ankle rehabilitation, focusing on joint mechanics, recovery phases, and therapeutic interventions. This quiz covers aspects such as mobility, aquatic therapy, and proprioceptive training. Perfect for students and professionals in physical therapy and sports medicine.