Foot and Ankle Pathology 2024 Student Version PDF

Foot and Ankle Pathology: 2024 Evie Tate, DPT, CSCS and Rich Willy, DPT, PhD School of Physical Therapy and Movement Science University of Montana University of Montana Movement Science Laboratory  Foot and ankle schedule: 2024...

Foot and Ankle Pathology: 2024 Evie Tate, DPT, CSCS and Rich Willy, DPT, PhD School of Physical Therapy and Movement Science University of Montana University of Montana Movement Science Laboratory  Foot and ankle schedule: 2024 Please come dressed and ready for lab, when indicated: Wednesday, 11/20 1-5: Lecture: tendinopathies, fasciopathy, tendon rupture Thurs ,11/21 8-10: LAB: tendinopathies, fasciopathy, and rupture examination Monday, 11/25 10-12: Lecture: Tendon ruptures and ankle sprains Monday, 11/25 1-3: Ankle sprain and fracture Tues, 11/26 8-10: LAB: Ankle sprain and fracture examination Monday, 12/2 10-12: Ankle sprain and fracture, bone stress injuries, foot injuries 14 hrs lecture, Monday, 12/2 1-3: Foot injuries and case studies 10 hrs lab Tuesday, 12/3 10-noon: LAB: Mobilization, Taping, Bracing 2 hrs exam Wednesday, 12/04 1-5: LAB: Ther ex, proprioception SKILLS CHECK FOOT AND ANKLE Thursday, 12/5 8-10: Foot injuries and Case studies Tuesday, 12/10: 8-10 FOOT AND ANKLE WRITTEN EXAM  The foot and ankle Pretty darn important tk A % of total support moment 7.8% 6.3% 3.3% f 17.2% 4 35.8% 40.2% load Hip 75.0% Knee 57.9% 56.5% Ankle University of Montana Motion Lab data Walking Running Single leg 1.3 m/s 5:05/km drop jump  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  Muscular contributions to running Muscle forces during running Muscle volume 10 7:40 minute/mile Muscle Forces 8 (Body Weights) 6 Fromhere 4 2 miffe Albracht et. al 2008 0 are more Soleus 64% PF Medial Gastroc: 25% ax s us ds gs rs s Important Lateral Gastroc: 12% oa iu xo M rin le ua m ps So le te Q ne st thoring o rf lu am oc Ili ta G an tr H In as Pl G Dorn, T. (2012) Journal of Experimental Biology. 215.11: 1944-1956; Albracht, K et al. (2008) J. Biomech 41.10: 2211-2218.  Why are plantarflexor muscle forces so high?  so Internal forces always exceed external forces External torque = Internal torque ForcevGRF * Moment armvGRF = ForceAchilles * Moment armAchilles 1 BW 1 BW * 15 cm = ForceAchilles * 4 cm 15 cm 3.8 BW 3.8 BW = ForceAchilles 4 cm lot ofload take a Takehome they can stand Do not 06Begged PC courtesy Jackie Merritt If pts Maganaris, C. N., Baltzopoulos, V., & Sargeant, A. J. (2000). In vivo measurement-based estimations of the human Achilles tendon moment arm. European Journal of Applied Physiology, 83, 363-369.  QUIZ! AT WHAT PHASE OF THE RUNNING CYCLE ARE ACHILLES TENDON LOADS THE GREATEST? mostamount of A. SWING PHASE cond 6 B. IMPACT PHASE (midstance) C. PROPULSIVE PHASE (toe off/terminal stance)  Plantarflexors are biased heavily toward dorsiflexion EEinfstrt w.IE optimal lengthfor Optimal length tIopwmtgEtgup Pfrom Soleus endof 0 30 DF Actively Donot letyourpatients Insufficient easily getthrough the entire Rome Exceptions Rostop Lieber, RL 2010 Adapted from Manal et al., 2008 Lieber, Richard L. Skeletal muscle structure, function, and plasticity. Edition 3.5. Lippincott Williams & Wilkins, 2010. Manal, K., et al. (2006). Optimal pennation angle of the primary ankle plantar and dorsiflexors: variations with sex, contraction intensity, and limb. J. of Appl. Biomech, 22(4), 255-263.  Dorsiflexion dominates stance Haveto workthese Rom 25 Walking Running 1.35 m/sec 25 3.3 m/sec 20 Dorsiflexion 20 Dorsiflexion 15 15 10 Degrees 10 5 5 Degrees % Stance % Stance 0 0 Plantarflexion -5 Plantarflexion -5 -10 -10 -15 -15  Tissue homeostasis model: Envelope of function Dye 2005 Injury risk High risk Adaptive homeostasis Homeostasis Stress Tissue shielded overload Low risk Low training load High training loads Applied loads Stress shielded as hazardous as tissue overload: Failure to prepare  More about getting strong, than being strong Mechanotherapy Loading MUSCLE stimulates: Hypertrophy MUSCLE Satellite cells BONE Applied Cell Remodeling BONE Loads Osteocytes response TENDON Compression, shear, Collagen Synthesis tension TENDON Tenoblasts ARTICULAR ARTICULAR CARTILAGE CARTILAGE Glycosaminoglycan Chondrocytes Synthesis Khan and Scott, 2011; Warden & Thompson 2017, Henrikson 2014, Roos 2005  Keys to success with your patients Be simple: Build capacity Don’t compromise with complexity Force production & strength gains are attenuated w/ unstable surfaces Cressey 2006, Behm 2015 Summary of Loading Principles for Important Tendons very slide Lift heavy and slow E 3-4 Sets, 4-8 reps, 3-second phases Make your reps count A lot of volume unneeded Monitor for day-after flareups Pain during exercise not informative Flareup of symptoms? REDUCE Reduce sets, not load TA SETS  Summary of Important principles for Muscle 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 This is our  Important Summary of Loading Principles for Bone Load heavy and eventually fast G Start off with slow, higher reps then progress to 3-4 Sets, 4-8 fast reps w Make your reps count A lot of volume unneeded u Loading should exceed activity More of your same will not build stronger bones Interpretation of diagnostic tests Reminder…what even is a likelihood ratio? LR= Probability of a finding in patients with a disease Probability of the same finding in patients without disease McGee S. Simplifying Likelihood Ratios. J Gen Intern Med. 2002 August; 17(8): 647–650.  Interpretation of diagnostic tests Important Y General approximations for increasing your confidence A LR+ ≥10 or LR- 35 years old Fluoroquinolone Use cero evegovin Family History  Clinical Reasoning Framework: Achilles Tendinopathy Subjective: Objective: Pain, stiffness upon waking, after sitting Special tests, if they Pain lessens with acute activity are good! Hope P ut Recent increase, change in Provocative testing workload Rule out alternative Athlete. Risk increases >40 y/o diagnoses Often male Clear red flags Tendon often swollen, may have Csingle focal lump palpableBump hadraise Hensley 2012 leg  Royal London Hospital Test Link Patient Position: Prone Sensitivity: 0.54 Pinch site of greatest tenderness Specificity: 0.91 Actively dorsiflex maximally +LR: 6.0 Now, pinch same portion that was -LR: 0.51 most tender Reiman 2014 Doesn'tchange If pn Cutoffs: +LR ≥ 5.0, -LR ≤ 0.2 paraentitis Positive: Pinch pain decreases with dorsiflexion  Rule out Sural nerve involvement Sural nerve provocation test SID Sultelis Inversion Dorriflex Sural nerve 1. Knee extension us distribution 2. Ankle dorsiflexion 3. Subtalar Inversion 4. Toe flexion 5. Hip flexion PC: Jake Mischke Pain increase with hip flexion? Sural nerve involvement  Outcome theurgit to them atthr end of measure MCID Give it On 6.5 points Achilles tendinopathy VISA-A McCormack 2015 8 points. Doing well if Achilles tendon rupture ATRS ≥85/100 Important ADL (8 points) Plantar fasciopathy FAAM Sports (9 points) Martin 2005 FAAM: ADL (8 points) Ankle Sprain FAAM and LEFS Sports (9 points) Martin 2005 LEFS: 12 points McCormack 2015 Kind of everything: Foot FAAM: FAAM ADL (8 points) and ankle Sports (9 points) Kind of everything: Lower MCID: 12 for lower leg LEFS leg McCormack 2015  VISA-A Victorian Institute of Sport Assessment (VISA-A) 8 item questionnaire VISA-A Scores range from 0-100 points “Full Recovery” >90 points Vestergard Iverson 2012 a MCID: 6.5 points McCormack 2015 Great for go 1s  FAAM Foot and Ankle Ability Measure 2 sections (ADL and Sports) Total of 84 points (ADL) and 32 points (Sports) Divide scored number by total (ex. 42/84=50%) to get the percentage MCID (Martin et al 2005): ADL (8 points) Sports (9 points)  Red flags: Achilles tendinopathy Red Flags Bilateral lower leg pain with neural/paresthesia presentations on Ct DVT Rule out overgrowth Pretended Plantar fasciopathy Sural nerve pain: clear it! Bony tetramer pops Haglund deformity and Sever’s disease kids Unilateral leg pain due to Lumbar radiculopathy Haglund deformity Calf strain/Tennis leg Heel pad syndrome and calcaneal stress fracture: hop test variations Popliteal artery entrapment syndrome  Sever’s Disease Epidemiology and evaluation Who? Adolescent, highly active, 7-15 y/o Swelling may be present Pain with passive Dorsiflexion Pain with active Plantarflexion, walk on toes Pain not bad upon waking, but inc. w/ loading Reduced DF ROM potentially due to L shortened ankle plantarflexors Calcaneal Squeeze test Mediolateral compression of the calcaneal growth plate  browing Sever’s Disease 2 38th're Treatment 10-12 mm Heel lift to reduce plantarflexor loads Control player loads Can’t run w/o limp? Take day off Calf stretching comfortable tolerable Soft tissue mobilization of calf mm. Fusion Key points Reduce training loads Yet fracture Self-limiting. Excellent natural history Team  Fill out pp Differentiating tests: Bestlase Injury/Diagnosis Mechanism always r/o competing dx’s Treatment strategy Recovery Achilles Period of relative Single leg hop test test painful, Reduce high tendon 3-4 mo’s tendinopathy overload single eshop (+)Royal London Hosp. Reduce loads, hightion say Repetitive, high Test loads Restore tendon months london Achilles tendon forces f Royal Restoretendon capacity Achilles Acute bout of relative Single leg hop test might capacity Reduce tendon 3-4 wks paratenonitis/ overload singleleghop be low pain, Reduce Tendon excursion, 3 4 (-) Royal Londonlow EEffimation weeks tenosynovitis High ankle excursion Hosp. Treat inflammation, mysite Test, Crepitis with excursion Load via low- excursion, but heavy withrow's under palpation Lord via lovebursion exercises 22pressure lentHenry Achilles tendon Rapid and forceful Inability to heel raise, Surgical & nonsurgical 6-24 mo’s rupture lengthening, Underlying (often Inclatittraise (+) Thompson test Controlled motion, progressive loading 621ns subclinical) tendon pathology THIEF  Best Exercises Achilles Tendinopathy: Treatment  Goal 1: Load management to enable continued activities Reminder: When are Achilles tendon forces the greatest? Mudstance Key point: Achilles tendon force highest approx. at max dorsiflexion, not push off  Ways to reduce load on Achilles Tendon Heel lift 6-9mm (moderate evidence) 12 weeks Brooks Launch Ultra's odrop Tolesper a shoe Activity modification 27 mm heel 10 mm drop Avoid hill running 17 mm forefoot North Face Avoid soft surfaces e.g., trails, sand Vectiv shoe: Avoid speedwork Rocker sole Reduce jumping Hookas For AchillesIgor ashared google Evie uses soundscool Linseycorbin.com for  my y Goal 2: Biomechanically informed graded loading program  Outline of Rehab Progressions: 1. Heavy, Slow 2A. Plyo Prep Exercises Resistance Training 2B. Plyos 3. Return to run/Return to hiking/Return to other activity  Tendon’s response to loading Protein degradation Protein synthesis Key Points: pekhe -separate loading sessions by 48 Net synthesis Protein synthesis turns hours Protein degradation -increased pain the Net degradation next morning means you did over did it-reduce VOLUME not weight for next Loading 24 hrs 48 hrs 72 hrs loading session session Adapted from Magnusson, 2010 IMPORTANT weightshouldbeheyenough Isometries The role of isometrics Do forgette upon two over on one pseforth Long hold, heavy isometrics helpful Highly irritable tendon, early stages of rehab Warmup for exercises or athletics For patients thromight bemore Parameters irritable 4x30-45 second holds Daily Key Point Isometrics hugely helpful, but insufficient alone for full recovery  Initiation of plyometric program Foot and ankle Target Achilles tendon and plantar fascia Banded assist Paloprep Good Exercises Plyometric program: Foot and ankle Pt Que Sample Program 1 set of 15 Knelis gift Monday 2 sets of 15 Wednesday 3 sets of 15 Friday Progress to next Phase Stationary hop Forward hop  Achilles tendinopathy rehabilitation Progression: If VAS ≤3/10 and Phase completed for ≥1 week Phase I week Phase II Daily, heavy isometrics t.EE Continue Phase I daily 3110 or on 4 sets 45 seconds Heavy isotonics, every other day: Below 1-2 Reps in Reserve Beyer Week 1-2: 3x12 reps Week 3: 4x10 reps protocol Week 4-on: 4x6 reps Control biomechanical loads Limit hills, speedwork Heel lift or shoes Linseycorbin.com Breda, S J., et al. "Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial." BJSM. 55.9 (2021): 501-509.  Achilles tendinopathy rehabilitation Progression: If VAS ≤3/10 with exercises and Phase completed for ≥1 week Phase III Phase IV Continue Phase I,II Continue Phase II heavy slow resistance exercises she likes D/C plyometrics Itinue Graded return; Phase I Plyometrics exercises as warmup 3-6x15 reps bilateral => unilateral Linseycorbin.com Linseycorbin.com Breda, S J., et al. "Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial." BJSM. 55.9 (2021): 501-509. YouDonot Have start the cantheed Room toRun Able Run to okay to Nowed Isometrics Do  Tendinopathy: How much pain is ok? Pain monitoring model 0-3/10 4-5/10 6-10/10 Safe Acceptable Excessive Silbernagel 2007; Thomeé R 1997 LOOET No detrimental effect on recovery if allowed up to 5/10 pain amtT Key point: Prior Achilles tendon pain is not a predictor of future rupture Increase in usual pain upon waking is the best barometer Silbernagel, KG et al. (2007). Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. AJSM, 35(6), 897-906; Silbernagel, K. G., Brorsson, A., & Lundberg, M. (2011). The majority of patients with Achilles tendinopathy recover fully when treated with exercise alone: a 5-year follow-up. AJSM, 39(3), 607-613.  Insertional Achilles tendinopathy s ion re s m p Lateral C o most feel Radsource.com sore Zwerver, Johannes, Michel Brink, and Jill Cook. "Tendon injuries in football players: fc barcelona 2021 tendon guide." (2021).  Other sources of internal and external compression of the Achilles tendon Tendon compression Occurs at site of tendon insertion Often due to footwear dorsiflexion Ting Activities that require high Rubbing, scraping of the tendon Nogastin cutting a hole in your Shaggy High tendon compression causes collagen disorganization and transition to fibrocartilage Zwerver et al., 2021 Rio E, et al. The pain of tendinopathy physiological or pathophy- siological? Sports Medicine.2014;44(1):9-23; Merry, K et al. "Foundational Principles and Adaptation of the Healthy and Pathological Achilles Tendon in Response to Resistance Exercise: A Narrative Review and Clinical Implications." Journal of Clinical Medicine 11.16 (2022): 4722.  Insertional Achilles tendinopathy: Treatment Zwerver et al., 2021 In early to mid-rehab: Jonsson et al., 2008 Avoid dorsiflexion with loading exercises. Slowly add back in during later stages Essential: Do not stretch If on solids ñe start at 0 Key points: Because Expect slower recovery due to Yitiggressively difficulty managing compressive loads at first Zwerver, Johannes, Michel Brink, and Jill Cook. "Tendon injuries in football players: fc barcelona 2021 tendon guide." (2021); Cardoso, T. B., Pizzari, T., Kinsella, R., Hope, D., & Cook, J. L. (2019). Current trends in tendinopathy management. Best practice & research Clinical rheumatology, 33(1), 122-140. Yo! What about stretching and mobilization for AT? NO Stretch?, Mobilize? Dorsiflexion Dorsiflexion excursion Achilles tendon absorbs more energy Probably not a good idea…. But maybe for plantar fasciopathy Absent evidence for these passive adjuncts for Achilles tendinopathy and plantar heel pain Leadingedgephysio.com physiotherapieuniverselle.com Evolutionsportsphysio.com activlifetech.com.au Acupuncture/ Graston? ASTYM? Ultrasound? Electrical stimulation? dry needling? SheDoesn'tDoanyofthem 071Prthem Recommendation: Time better spent on expanding patient’s load capacity Martin, Achilles pain CPG, JOSPT(2018); Katzap, JOSPT (2018); Martin, Plantar heel pain CPG, JOSPT (2014) Calf Strain/Tear  Calf strain/tear MOI: Forceful eccentric contraction. Sudden onset, some are gradual Soleus come on more me Grades I: Partial tear (