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?

<p>Both B and C (B)</p> Signup and view all the answers

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

<p>Insufficient lengthening (D)</p> Signup and view all the answers

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

<p>More volume correlates with more hypertrophy. (A)</p> Signup and view all the answers

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

<p>Loading should be less than activity levels. (B)</p> Signup and view all the answers

What is the recommendation regarding training to failure?

<p>It is important to leave 1-3 reps in reserve. (C)</p> Signup and view all the answers

What does a likelihood ratio (LR) compare?

<p>The probability of a finding in diseased patients to that of non-diseased patients. (A)</p> Signup and view all the answers

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

<p>Stiffness upon waking that improves with activity. (D)</p> Signup and view all the answers

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

<p>Load management (C)</p> Signup and view all the answers

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

<p>Complete rupture (A)</p> Signup and view all the answers

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

<p>Heavy loading with low excursion (A)</p> Signup and view all the answers

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

<p>6-24 months (A)</p> Signup and view all the answers

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

<p>Progressive loading with controlled motion (A)</p> Signup and view all the answers

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

<p>Avoid dorsiflexion during loading exercises (B)</p> Signup and view all the answers

What should be avoided in the treatment of Achilles tendinopathy?

<p>Stretching the Achilles tendon (B)</p> Signup and view all the answers

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

<p>Difficulty managing compressive loads (B)</p> Signup and view all the answers

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

<p>Evidence supporting them is absent (A)</p> Signup and view all the answers

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

<p>Expanding the patient's load capacity (B)</p> Signup and view all the answers

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

<p>Forceful eccentric contraction (A)</p> Signup and view all the answers

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

<p>Gradual re-introduction of dorsiflexion (D)</p> Signup and view all the answers

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

<p>They require careful management (C)</p> Signup and view all the answers

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

<p>Volume of the exercises (D)</p> Signup and view all the answers

How long should separate loading sessions be spaced apart?

<p>48 hours (B)</p> Signup and view all the answers

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

<p>30-45 seconds (A)</p> Signup and view all the answers

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

<p>They should be long hold, heavy isometrics (B)</p> Signup and view all the answers

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

<p>VAS score of 3/10 (B)</p> Signup and view all the answers

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

<p>1 set of 15 (B)</p> Signup and view all the answers

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

<p>Controlling biomechanical loads (C)</p> Signup and view all the answers

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

<p>Heavy isometrics (A)</p> 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?

<p>3x12 to 4x10 (C)</p> Signup and view all the answers

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

<p>Shoes with a heel lift (C)</p> Signup and view all the answers

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

<p>≤3/10 (B)</p> Signup and view all the answers

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

<p>6-10/10 (B)</p> Signup and view all the answers

What is the key consideration regarding prior Achilles tendon pain?

<p>It has no impact on future ruptures. (D)</p> Signup and view all the answers

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

<p>Incorporate them after completing Phase I only. (D)</p> Signup and view all the answers

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

<p>Increase in usual pain upon waking (A)</p> Signup and view all the answers

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

<p>Discontinue exercises (B)</p> Signup and view all the answers

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

<p>Consider it an acceptable pain level (A)</p> Signup and view all the answers

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

<p>Increasing muscle endurance and strength (A)</p> Signup and view all the answers

Flashcards

Plantarflexors biased toward dorsiflexion

During the propulsive phase, plantarflexor muscles are heavily influenced to dorsiflex the foot.

Optimal length for plantarflexion

The ideal length of the plantarflexor muscles for efficient movement during the propulsive phase.

Insufficient plantarflexion

Inability of plantarflexion muscles to perform the necessary movement efficiently.

Soleus in plantarflexion

The Soleus muscle plays a role in plantarflexion.

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Optimal pennation angle

The ideal angle of the muscle fibers for efficient force production during plantarflexion, varying by gender, intensity, and limb.

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Muscle Hypertrophy Principle

More volume leads to more muscle growth.

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Bone Loading Principle

Load heavy and potentially fast to build stronger bones.

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Likelihood Ratio (LR)

A measure of how likely a finding is in someone with a disease, compared to someone without it.

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Achilles Tendinopathy Subjective Symptoms

Includes pain, stiffness upon waking or after sitting, pain relieved by activity and possibly a recent increase in workload.

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Bone Loading

Load should be higher than the activity itself so the body needs to work harder to adapt to build stronger bones.

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Achilles Tendon Rupture

A complete tear of the Achilles tendon, often caused by rapid forceful lengthening of the tendon. Symptoms include inability to heel raise and a positive Thompson test.

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Achilles Tendon Forces - When Highest?

Achilles tendon forces are highest during the stance phase of gait, particularly at heel push-off.

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Treatment Goals for Achilles Tendinopathy

The primary goal of treatment is load management to enable continued activity while promoting healing and minimizing pain.

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Thompson Test

A clinical test to assess the integrity of the Achilles tendon. It involves squeezing the calf muscles and observing for plantarflexion of the foot.

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Achilles Tendinopathy Treatment Duration

Treatment for Achilles tendon problems can range from 6 to 24 months depending on the severity and other factors.

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Pain Monitoring Model

A system to guide exercise intensity based on pain levels, categorizing pain as safe (0-3/10), acceptable (4-5/10), or excessive (6-10/10).

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LOOET

Load to the point of pain

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Achilles Tendinopathy Rehabilitation Phases

A progressive program with four phases focusing on pain level and exercise intensity.

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Phase III

Involves plyometrics and graded return to activity, with pain levels at or below 3/10.

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Phase IV

Focuses on heavy slow resistance exercises and a return to sport-specific activities, with pain levels at or below 3/10.

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Prior Achilles Pain

Does not predict future Achilles tendon rupture.

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Increase in Usual Pain Upon Waking

The best indicator of Achilles tendinopathy recovery.

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Progressive Tendon-Loading Exercise Therapy

A method of rehabilitation that gradually increases the load on tendons to promote healing and functional recovery.

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Loading Sessions

Separate loading sessions by at least 48 hours to allow for tissue recovery and adaptation.

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Overloading Signal

Increased pain the next morning after a loading session indicates you may have overdone it. Reduce the volume or intensity for the next session.

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Isometrics for Tendons

Isometric exercises, holding a muscle in a contracted position, can be beneficial for tendon rehabilitation, especially in early stages.

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Isometrics: Effective, But Not Enough

Isometric exercises are extremely helpful, but they are not sufficient alone for full tendon recovery.

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Plyometric Program: Foot and Ankle

A program designed to gradually increase the intensity and volume of jumping exercises to help strengthen the Achilles tendon and plantar fascia.

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Plyometric Program: Progression

Begin with stationary hops, progress to forward hops, then increase sets and reps as the tendon recovers.

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Achilles Tendinopathy Rehabilitation: Phase II

Introduce heavy isotonic exercises, performed every other day, building on Phase I progress with more dynamic movement.

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Achilles Tendinopathy Rehabilitation: Progression Criteria

Advance to the next phase once the pain level is 3/10 or less and the previous phase has been completed for at least one week.

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Biomechanical Load Management

Avoid activities that put excessive stress on the Achilles tendon, such as running uphill or sprinting.

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Achilles Tendinopathy: Early Rehab

In the early stages of Achilles tendinopathy rehab, avoid loading exercises that require dorsiflexion. Slowly introduce dorsiflexion as you progress through rehab.

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Achilles Tendinopathy: Stretching

Stretching is not recommended for Achilles tendinopathy, as it can increase tendon loading and delay healing.

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Achilles Tendinopathy: Recovery Time

Expect a slower recovery from Achilles tendinopathy due to the challenges of managing compressive loads on the tendon.

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Calf Strain/Tear: Mechanism of Injury

Calf strains/tears occur due to forceful eccentric contractions, usually sudden onset, sometimes gradual.

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Calf Strain/Tear: Soleus

The soleus muscle is often more involved in calf strains/tears compared to the gastrocnemius.

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Calf Strain/Tear: Grades

Calf strains/tears are categorized into grades based on the severity of the tear. Grade I is a partial tear, Grade II is a more significant tear, and Grade III is a complete tear.

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Achilles Tendinopathy: Passive Treatments

There is limited evidence to support the use of passive treatments like stretching, mobilization, acupuncture, or electrical stimulation for Achilles tendinopathy.

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Achilles Tendinopathy: Treatment Focus

The most effective treatment for Achilles tendinopathy is focused on expanding the patient's load capacity and strengthening the tendon.

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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.

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