Physiotherapy Chapter on Gait Propulsion

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Questions and Answers

What is the primary role of the plantarflexors during the propulsive phase of gait?

Assisting in toe-off (correct)

Decelerating the limb

Maximizing knee flexion

Facilitating dorsiflexion

What is an important consideration for patients regarding their movement during the propulsive phase?

Avoiding adequate propulsion through the forefoot (correct)

Encouraging extended dorsiflexion

Preventing excessive plantarflexion

Allowing easy transitions of the center of mass

Which muscle is indicated as having an optimal length during the propulsive phase?

Tibialis anterior

Gastrocnemius

Soleus (correct)

Peroneus longus

What does the term 'optimal pennation angle' refer to in the context of the primary ankle muscles?

Both B and C Signup and view all the answers

What issue should be avoided concerning the adjustment of the soleus during movement?

Insufficient lengthening Signup and view all the answers

What is the key principle regarding volume and hypertrophy in muscle training?

More volume correlates with more hypertrophy. Signup and view all the answers

Which of the following is NOT emphasized in loading principles for bone?

Loading should be less than activity levels. Signup and view all the answers

What is the recommendation regarding training to failure?

It is important to leave 1-3 reps in reserve. Signup and view all the answers

What does a likelihood ratio (LR) compare?

The probability of a finding in diseased patients to that of non-diseased patients. Signup and view all the answers

In the context of Achilles tendinopathy, which subjective symptom is commonly noted?

Stiffness upon waking that improves with activity. Signup and view all the answers

Which treatment method is primarily aimed at managing load to continue activities for Achilles tendinopathy?

Load management Signup and view all the answers

What is indicated by a positive Thompson test in the context of Achilles tendon injuries?

Complete rupture Signup and view all the answers

In the management of Achilles tendon injuries, which exercise technique is considered most beneficial?

Heavy loading with low excursion Signup and view all the answers

What timeframe is typically associated with the nonsurgical treatment approaches for an Achilles tendon rupture?

6-24 months Signup and view all the answers

What should be the primary focus in the rehabilitation of achilles tendinopathy?

Progressive loading with controlled motion Signup and view all the answers

What is a key recommendation during early to mid-rehabilitation for insertional Achilles tendinopathy?

Avoid dorsiflexion during loading exercises Signup and view all the answers

What should be avoided in the treatment of Achilles tendinopathy?

Stretching the Achilles tendon Signup and view all the answers

What factor contributes to a slower recovery from insertional Achilles tendinopathy?

Difficulty managing compressive loads Signup and view all the answers

In the context of passive adjuncts, what is stated about their efficacy for Achilles tendinopathy?

Evidence supporting them is absent Signup and view all the answers

What should be the focus of treatment rather than passive adjuncts for Achilles tendinopathy?

Expanding the patient's load capacity Signup and view all the answers

What is the mechanism of injury (MOI) commonly associated with calf strains or tears?

Forceful eccentric contraction Signup and view all the answers

Which of the following is a key characteristic of the early stages of rehab for Achilles tendinopathy?

Gradual re-introduction of dorsiflexion Signup and view all the answers

What consideration should be kept in mind when dealing with compressive loads in Achilles tendinopathy recovery?

They require careful management Signup and view all the answers

What should be reduced if there is increased pain the next morning after a loading session?

Volume of the exercises Signup and view all the answers

How long should separate loading sessions be spaced apart?

48 hours Signup and view all the answers

What is the recommended hold duration for isometric exercises during rehabilitation?

30-45 seconds Signup and view all the answers

What is a key characteristic of the isometrics used in the early stages of tendon rehabilitation?

They should be long hold, heavy isometrics Signup and view all the answers

What symptom indicates a successful progression in the Achilles tendinopathy rehabilitation program?

VAS score of 3/10 Signup and view all the answers

In the plyometric program, how many sets should be performed on the first Monday?

1 set of 15 Signup and view all the answers

What aspect of the rehabilitation protocol is emphasized for the treatment of Achilles tendinopathy?

Controlling biomechanical loads Signup and view all the answers

Which type of loading regimen is suitable for individuals with a highly irritable tendon?

Heavy isometrics Signup and view all the answers

What is the recommended progression pattern of repetitions from Week 1 to Week 3 for isotonics in Achilles rehabilitation?

3x12 to 4x10 Signup and view all the answers

What type of shoe modification might be recommended during the rehabilitation of Achilles tendinopathy?

Shoes with a heel lift Signup and view all the answers

What VAS score indicates that it is safe to progress in exercise therapy for patients with patellar tendinopathy?

≤3/10 Signup and view all the answers

According to the pain monitoring model, which score is categorized as excessive pain?

6-10/10 Signup and view all the answers

What is the key consideration regarding prior Achilles tendon pain?

It has no impact on future ruptures. Signup and view all the answers

What is the recommended approach when returning to plyometric exercises during rehabilitation?

Incorporate them after completing Phase I only. Signup and view all the answers

What should be used as the best indicator of recovery during Achilles tendinopathy rehabilitation?

Increase in usual pain upon waking Signup and view all the answers

In the context of progressive loading exercise therapy, what does the term 'D/C' refer to?

Discontinue exercises Signup and view all the answers

What progression should be taken if the pain level remains at 4-5/10 during rehabilitation exercises?

Consider it an acceptable pain level Signup and view all the answers

What does the phase related to heavy slow resistance exercises focus on in the rehabilitation process?

Increasing muscle endurance and strength Signup and view all the answers

Study Notes

Foot and Ankle Pathology: 2024

Course Instructor: Evie Tate, DPT, CSCS and Rich Willy, DPT, PhD
Institution: University of Montana, School of Physical Therapy and Movement Science
Location: University of Montana Movement Science Laboratory

Schedule 2024

Lectures: Tendinopathies, fasciopathy, tendon rupture (11/20/2024); Tendon ruptures and ankle sprains (11/25/2024); Foot injuries and case studies (12/2/2024)
Labs: Tendinopathies, fasciopathy, and rupture examination (11/21/2024); Ankle sprain and fracture examination (11/26/2024); Mobilization, Taping, Bracing (12/3/2024); Ther ex, proprioception SKILLS CHECK FOOT AND ANKLE (12/4/2024)
Exam: Foot and Ankle Written Examination (12/10/2024)

Foot and Ankle: Pretty Darn Important

Walking (1.3 m/s): 75% of total support moment is from hip and knee, only 7.8% is from the ankle
Running (5:05/km): 57.9% of total support moment is from the hip and knee, 6.3% of the total support moment is from the ankle
Single leg drop jump: 56.5% of total support moment is from the hip and knee, only 3.3% of the total support moment is from the ankle

The 3 Functions of the Foot and Ankle

Base of support: Mobile adaptor (wt acceptance): Rigid lever arm (toe off)
Subtalar joint locks out, windlass mechanism

Muscle Forces During Running

Glute Max, Iliopsoas, Hamstrings, Quads, Plantarflexors
Soleus 64%, Medial Gastroc: 25%, Lateral Gastroc: 12%

Why are Plantarflexor Muscle Forces So High?

Internal forces always exceed external forces
Force, GRF * Moment arm, GRF = Force, Achilles * Moment arm, Achilles
1 BW * 15 cm = Force, Achilles * 4 cm
3.8 BW = Force, Achilles

QUIZ!

At what phase of the running cycle are Achilles tendon loads the greatest?
Correct Answer: IMPACT PHASE (midstance)

Plantarflexors are Biased Heavily Toward Dorsiflexion

Optimal length for Soleus is 0-30' DF
Do not let patients easily get through the entire ROM, except in cases of posterior
Do not let patients easily get through entire ROM; exceptions: Post-op

Tissue Homeostasis Model: Envelope of Function (Dye 2005)

Stress shielded (Low training load) is as hazardous as tissue overload (High training loads and Applied loads)

Mechanotherapy

Loading stimulates: Muscle satellite cells, Osteocytes, Tenoblasts, Articular cartilage chondrocytes
Cell response: Muscle hypertrophy, Bone remodeling, Collagen synthesis, Cartilage glycosaminoglycan Synthesis

Keys to Success with Your Patients

Be simple: Build capacity
Don't compromise with complexity: Force production & strength gains are attenuated w/ unstable surfaces

Summary of Loading Principles for Tendons/Summary of Loading Principles for Muscles/Summary of Loading Principles for Bone

Lift heavy and slow
Make your reps count
Monitor for day-after flare-ups
Pain during exercise not informative
Flare-up of symptoms? Reduce sets, not load
More volume, more hypertrophy
Opposite of bone and tendon
Train heavy
Eccentric might make a lot of sense
Training to failure not important Consider 1-3 reps in reserve

Interpration of Diagnostic Tests

Clinical Reasoning Framework

Treatment Framework

Load Modifications-Mechanotherapy-Removing load modifications, return to PLOF

Most Common Pathologies Per Type

Diagnosis- Understand applied biomechanical loads–Manage applied loads (reduce initially)–Increase tissue tolerance (graded exposure)

What Even is a Tendinopathy?

Loss and disruption of collagen structure (instead of parallel becomes more disorganized)
Thinning of collagen fibers
Fatty infiltration
Non-collagen tissue formation (fibrocartilage sometimes)

Insertional vs Mid-Substance Tendinopathy (Cook and Purdam, 2009, 2012)

Insertional: Due to tendon wrapping, external loading, suspect compression
Mid-substance: Suspect excessive tensile loading

Insertional Achilles Tendinopathy

Paratenonitis

Achilles Tendinopathy Risk Factors (Silbernagel and Crossley, 2015)

Decreased plantarflexor strength
Loss of tendon stiffness
Systemic contributors
Psychosocial and Previous History
Male >35 years old
Fluoroquinolone Use
Family History
Change in training loads
Tendon tensile loads
Tendon compression
Change in footwear
Running hills

Clinical Reasoning Framework: Achilles Tendinopathy

Subjective:*
Pain, stiffness upon waking, after sitting
Pain lessens with acute activity
Recent increase or change in workload
Athlete, Risk increases >40 y/o
Often male
Tendon often swollen, may have focal lump, palpable bump
Objective:*
Special tests, if they are good
Hop for speed
Hop for height
Provocative testing, Rule out alternative diagnoses, Clear red flags, single leg heel raise

Royal London Hospital Test

Sensitivity: 0.54
Specificity: 0.91
+LR: 6.0
-LR: 0.51
Positive: Pinch pain decreases with dorsiflexion

Rule out Sural Nerve Involvement

Outcome Measure

VISA-A

FAAM

Red Flags: Achilles tendinopathy

Sever's Disease

Treatment

Differentiating Tests

Why Early Motion, Post-Achilles Rupture?

Achilles Tendon Rupture: Strength Deficits

Post-Achilles Tendon Rupture Rehabilitation

Example: Early Mobilization Program (Weeks 0-2, 2-6, 6-8, 8-10)

Example: Return to Sport after ATR (Weeks 10-16)

Posterior Tibial Tendon Dysfunction (PTTD)

Examination: Stage 1 PTTD

Stage 1, 2, 3, & 4 PTTD

Ankle Sprains and Instability

Static/Dynamic Stabilizers (Medial/Lateral Ankle)

Risk Factors: Acute Lateral Ankle Sprain

Grading of Lateral Ankle Sprains

Diagnosis/Classification

Ottawa Foot and Ankle Rules

Associated Injury: Jones Fracture

5th Metatarsal Fracture

Bone Stress Injuries (BSI)

What is a "Bone Stress Injury"?

Bone stress injuries lag 4-10 weeks behind spikes in workload

Bone is most susceptible to Tension and Torsion

High vs. Low Risk Stress Fractures

All Increase Risk of Bone Stress Injury in High School Runners… But Which Are Best Predictors?

Prior Bone Stress Injury Increases Risk of Subsequent BSI by 6-fold. Why?

Tibial Bone Stress Injuries

Medial Tibial Stress Syndrome

Medial Tibial Stress Syndrome: Treatment

Nerve Compression Injury: Tarsal Tunnel and Interdigital Neuralgia

Tarsal Tunnel Syndrome

Examination: Tarsal Tunnel Syndrome

Treatment: Tarsal Tunnel Syndrome

Examination: Interdigital Neuralgia

Conservative Treatment: Interdigital Neuralgia

Medical Management: Interdigital Neuralgia

Metatarsalgia

Examination: Metatarsalgia

Treatment: Hallux Rigidus

Hallux valgus

Turf Toe: Sprain to 1st MTP

Turf Toe: Sprain to 1st MTP Management

Lisfranc Injury

Lisfranc injury

Associated Injury: Peroneal Tendon Dislocation/Subluxation

Peroneal Subluxation Test

Associated Injury: Talar Dome Lesions

Interaction of Task and Environment for Balance Training

Areas of Progression for Balance Activities

Stable Person, Stable Environment/Moving Person, Stable Environment/Stable Person, Moving Surface/Moving Person in a Moving Environment

Return to Activity Phase

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Description

This quiz focuses on the role of plantarflexors during the propulsive phase of gait and considerations for patient movement. It covers the optimal length of muscles, pennation angles, training principles, and common symptoms of Achilles tendinopathy. Test your knowledge on the physiological principles related to human movement and injury management.