Ankle and Foot Conditions Acute Injuries Seminar (PDF)

Ankle and foot conditions Acute injuries Seminar Dr Paula Beckenkamp Senior Lecturer Discipline of Physiotherapy TEQSA PRV12057 CRICOS 00026A Acknowledgement of country We recognise and pay respect to the Elders a...

Ankle and foot conditions Acute injuries Seminar Dr Paula Beckenkamp Senior Lecturer Discipline of Physiotherapy TEQSA PRV12057 CRICOS 00026A Acknowledgement of country We recognise and pay respect to the Elders and communities – past, present, and emerging – of the lands that the University of Sydney's campuses stand on. For thousands of years they have shared and exchanged knowledges across innumerable generations for the benefit of all. Learning outcomes At the end of this mini-lecture, students should be able to: - Demonstrate clinical reasoning to triage and identify common acute musculoskeletal conditions of the foot and ankle - Describe mechanism of injury, presentation and prognosis of common acute musculoskeletal conditions of the foot and ankle - Identify impairments associated with common acute musculoskeletal conditions and devise an appropriate management plan to address these impairments The University of Sydney  Body chart Case 1: Sakina - Sakina is 23 years old, university student and recreational basketball player. Just looking at the body chart, what comes to mind as possible provisional hypotheses? PA I/T sharp 8/10 Constant 2/10 The University of Sydney Diagnostic triage of the foot and ankle Consider what is more serious that needs to be screened and requires referral What else you want to know about Sakina and her injury? The University of Sydney Brukner & Khan. Clinical Sports Medicine. 2017, Ch 41 Current history - Sakina twisted her right ankle while playing basketball last night (can’t remember if lateral or medial). - She felt a lot of pain, was unable to continue to play and hopped off the court with another player’s help. - Sakina can’t remember hearing anything at the time of the injury (but there was a lot of noise). - The ankle swelled up within the 1st hour and although the pain reduced slightly, it remains quite strong. The University of Sydney 24-hour behaviour - Night: - Woke up a few times because of pain, that increased with moving the ankle and changing position in bed. Would be able to go back to sleep, kept the right foot/ankle elevated on a pillow. - AM: - Pain increased once out of bed and attempted to move and walk. The University of Sydney Aggravating/Easing activities - Aggravating activities - Any activity that involves moving the ankle and weight bearing - Easing activities - Not moving or weight bearing and keeping the ankle/foot elevated The University of Sydney Past history - Sakina has sprained her ankle before, though never had this much pain and was always able to move and walk afterwards. She never sought treatment and would always be able to return to play after a few days (2-3). - She felt her ankle giving way sometimes while playing, but this never bothered her too much. The University of Sydney Social history - Sakina is a university student, on her last year of a History degree - Plays basketball 2 times/week (has been since she was 12 years old) and runs 3-4 times/week - Shares accommodation with 2 friends, parents live about 1 hour away - Lives in a unit on the second floor (no elevator) - Works part-time as a shop assistance in a supermarket (next shift is in 2 days) The University of Sydney Special questions - General health: Good (exercises, eats well and doesn’t usually get sick) - Unexplained weight loss: No - Steroids: Nil - Medication: Nurofen every 6 hours (last time about 2 hours ago) Anything else you would like to know? What are your provisional hypotheses now? The University of Sydney Diagnostic triage of the foot and ankle The University of Sydney Brukner & Khan. Clinical Sports Medicine. 2017, Ch 41  Clinical reasoning and triage Structure Hypothesis Features Consider: - Anything that needs referral – priority - What is more → least likely The University of Sydney  Clinical reasoning and triage Structure Hypothesis Features Dist tib/fibular, Fracture Twisting MOI, location of pain, constant pain, base of 5th MT increase pain with WB and inability to walk, pain and tenderness on palpation (OAR +ve) ATFL, CFL, PTFL Sprain/tear Twisting MOI, location of pain (more lateral), increased pain with WB and movement, pain/tenderness on palpation, limited AMT=PMT, Ant drawer and/or talar tilt +ve AITFL Sprain/tear Same as above, but pain will be more anterior (syndesmosis) (high) and ER stress test +ve The University of Sydney  Clinical reasoning and triage Structure Hypothesis Features Peroneal tendon/s Injury at the lat Twisting MOI, location of pain (lateral), increase malleolus pain with movement (particularly eversion), pain and tenderness on palpation of peroneal tendons, pain with eversion IMT TMT joint Sprain/tear Twisting MOI, location of pain (more anterior (Lisfranc) midfoot), bruising could extend to plantar aspect of the midfoot, increased pain with WB and movement, pain/tenderness on palpation, limited AMT=PMT (more on the toes than ankle) The University of Sydney Anything else we should consider? Physical examination plan - What should be your priority? - Any serious pathologies that we need to screen for? What will the screening involve? - What would the patient be able to complete today? - Consider irritability level - What aspects of the patient presentation need to be considered? - Positions that increase the pain (can the patient stand/weight bear?), amount of swelling and impact on assessment - What assessments will help you identify the likely diagnosis? - What structures need to be palpated, what movement directions, what special tests… The University of Sydney Physical examination plan LOOK FEEL MOVE - What would you look for? - What would you palpate? - What positions/views? - Think about the relevant structures that - What movements/function? you need to cover The University of Sydney Physical examination Observation - Static - Bruising on the antero-lateral aspect of the right ankle and significant swelling on the right ankle/foot - Dynamic - Walking: can walk with some difficulty (limping), reduced stride phase on the right leg - Standing: can weight bear on the right for a short time, weight shifted to the left leg The University of Sydney Physical examination Palpation - Widespread pain on the antero-lateral aspect of the ankle (more on the lateral), however, difficult to locate the exact locations. Some pain/tenderness on the distal fibula (more anterior). Can we confidently exclude a fracture? The University of Sydney Physical examination AMT - Limited and painful movements, particularly inversion (P1 PA 7/10) and plantarflexion (P1 PA 5/10). Both have about 1/3 of movement compared with the left ankle. PMT - Limited and painful movements, similar ranges compared with AMT. Swelling What else could we - Figure of 8 R: 88 cm assess at this stage? - Figure of 8 L: 65 cm The University of Sydney Management Impairments - What are the main impairments to address today? Education - What is the likely diagnosis? - What were you able to exclude? - How is the patient likely to progress over the next few days? - How can they manage pain, swelling, reduced ROM and difficulty walking? The University of Sydney Presentation 5 days later Progress: - Pain has reduced (now PA I/T 6/10), able to WB more and walk without crutches. No longer taking Nurofen to manage pain. Observation - Static: Light bruising still present on the lateral aspect of the right ankle and some swelling on the right ankle/foot (though much less) - Dynamic: Can WB, walking still limping, but with better heel → toe motion The University of Sydney Presentation 5 days later Palpation - Pain on the ATFL and CFL areas. No other areas of pain or tenderness. AMT - Inversion R ankle: PA P2 5/10, ½ movement compared to left - Plantarflexion R ankle: PA P2 4/10, 40o (55o on the left ankle) PMT - Inversion and PF limited around the same range as AMT on the right side, with some pain (more in inversion than PF) The University of Sydney Presentation 5 days later Swelling - Figure of 8 R: 71 cm - Figure of 8 L: 65 cm Special tests - Anterior drawer: positive (some laxity and no end feel) - Talar tilt: positive (some laxity with pain, with end feel) - ER stress test: negative IMT - Evertors: negative The University of Sydney Diagnosis Lateral ankle sprain - ATFL: grade III (complete tear) - CFL: grade II (partial teal) The University of Sydney Impairments - Pain - Swelling - Limited range of motion - Difficulty walking What else you would want to assess moving forward? The University of Sydney Initial management - Immobilisation in boot for ~1 week (weight bearing allowed) - Active ROM exs → remove the boot to move the ankle in all directions (often) - Elevation, compression - Normal walking pattern once out of the boot and start strengthening (particularly evertors) Consider impact of immobilisation on the impairments (i.e., strength, joint stiffness…) The University of Sydney Moving forward Assessment and address the following impairments: - Muscle strength - Balance (static, dynamic) - Motor control - Look at techniques related to basketball and running that could have contributed to injury (biomechanics) - Return to sport plan The University of Sydney  Body chart Case 2: Michael (Myers) - Michael is 40 years old, builder and recreational soccer player. Just looking at the body chart, what comes to mind as possible provisional hypotheses? PA I/T sharp 8/10 Constant 4/10 The University of Sydney Diagnostic triage of the foot and ankle Consider what is more serious that needs to be screened and requires referral What else you want to know about Jack and her injury? The University of Sydney Brukner & Khan. Clinical Sports Medicine. 2017, Ch 41 Current history - Michael had a fall at work yesterday (about 2-3 m) and felt an immediate pain in his right midfoot/anterior ankle. - Was not able to walk initially, hopped out of site and went home (unable to drive, a colleague took him home). - There was significant swelling soon after injury, followed by bruising of the midfoot (both dorsal and plantar aspect). The University of Sydney 24-hour behaviour - Night: - Woke up a few times because of pain, that increased with moving and changing position in bed. Had difficulty sleeping due to pain, kept the right foot/ankle elevated on a pillow. - AM: - Pain increased once out of bed and attempted to move and walk (has been hopping, holding on furniture at home). The University of Sydney Aggravating/Easing activities - Aggravating activities - Any activity that involves moving the ankle/foot/toes and weight bearing - Easing activities - Not moving or weight bearing, keeping the ankle/foot elevated and pain killer (Nurofen every 4 hours) The University of Sydney Past history - Had an ACLR 5 years ago (hamstring graft) on the same side, had physio for about 8-9 months and really enjoyed it (hence came to see you again). He injured his ACL while playing soccer. - Had a few episodes of LBP, but didn’t need to seek treatment, episodes resolved within a few days/week. The University of Sydney Social history - Michael is married, 1 child (4 years old boy) - Plays soccer 1-2 times/week (has been for 20+ years) and runs or goes to the gym 2-3 times/week - Lives in a house in the suburbs (no stairs, only a few steps in the front) - Self-employed builder, wife works full-time as a teacher and son goes to day- care full-time - No family (apart from wife and son) in Australia (all overseas) The University of Sydney Special questions - General health: Good - Unexplained weight loss: No - Steroids: Nil - Medication: 1-2 Nurofen every 4 hours (last time about 1 hour ago) Anything else you would like to know? What are your provisional hypotheses now? The University of Sydney Diagnostic triage of the foot and ankle The University of Sydney Brukner & Khan. Clinical Sports Medicine. 2017, Ch 41  Clinical reasoning and triage Structure Hypothesis Features Consider: - Anything that needs referral – priority - What is more → least likely The University of Sydney  Clinical reasoning and triage Structure Hypothesis Features Navicular, talus, Fracture MOI (fall), location of pain, constant pain, cuboid, increased pain with WB and inability to walk, pain cuneiforms, MT and tenderness on palpation (OAR +ve) Twisting MOI, location of pain (more anterior TMT joint Sprain/tear midfoot), bruising extending to plantar aspect of (Lisfranc) the midfoot, increased pain with WB and movement, pain/tenderness on palpation, limited AMT=PMT (more on the toes/midfoot than ankle) The University of Sydney  Clinical reasoning and triage Structure Hypothesis Features TC (ankle) joint Osteochondral MOI (fall), location of pain (more anterior/medial), lesion increased pain with WB and movement, pain/tenderness on palpation, limited AMT=PMT (more ankle than midfoot/toes) AITFL Sprain/tear MOI (fall/twisting), location of pain (more anterior), (syndesmosis) increased pain with WB and movement, pain/tenderness on palpation and ER stress test +ve The University of Sydney Anything else we should consider? Physical examination plan - What should be your priority? - Any serious pathologies that we need to screen for? What will the screening involve? - What would the patient be able to complete today? - Consider irritability level - What aspects of the patient presentation need to be considered? - Positions that increase the pain (can the patient stand/weight bear?), amount of swelling and impact on assessment - What assessments will help you identify the likely diagnosis? - What structures need to be palpated, what movement directions, what special tests… The University of Sydney Physical examination plan LOOK FEEL MOVE - What would you look for? - What would you palpate? - What positions/views? - Think about the relevant structures that - What movements/function? you need to cover The University of Sydney Physical examination Observation - Static - Bruising on the the right midfoot (all around) and significant swelling on the right ankle/foot - Dynamic - Walking: cannot walk without assistance, hops on furniture - Standing: can weight bear about 20-30% of body weight on the right, weight shifted to the left leg The University of Sydney Physical examination Palpation - Widespread pain on the right midfoot (more on the medial side) however, difficult to locate the exact locations. Some pain/tenderness on the navicular bone. Can we confidently exclude a fracture? The University of Sydney Physical examination AMT - Limited and painful movements, particularly inversion (P1 PA 8/10) and eversion (P1 PA 7/10). Both have very little movement (about ¼) compared with the left ankle/foot. Moving the toes is also painful on the right. PMT - Limited and painful movements, similar ranges compared with AMT. Swelling What else could we - Figure of 8 R: 108 cm assess at this stage? - Figure of 8 L: 79 cm The University of Sydney Management Impairments - What are the main impairments to address today? Education - What is the likely diagnosis? - What were you able to exclude? Do you need to refer this patient for imaging? - How is the patient likely to progress over the next few days? - How can they manage pain, swelling, reduced ROM and difficulty walking? The University of Sydney Management Referral - Michael needs to be referred for imaging to exclude/confirm fracture. Education - What is the likely diagnosis? - How would you explain this to Michael? Is the referral urgent? Should he go to a GP, orthopaedic Dr or ED? - How can they manage pain, swelling, reduced ROM and difficulty walking in the meantime? What is the priority for Michael TODAY? The University of Sydney Presentation 5 weeks later Referral letter from orthopaedic Dr: - Please see Mr Michael Myers, who sustained a navicular fracture 5 weeks ago, managed conservatively NWB on a boot for 4 weeks. Fracture healed well, currently able to WBAT, no need for crutches. Presents pain on movement and WB on the right side, stiffness and general lower limb weakness on the right leg/foot. - No restrictions of movement or activities. The University of Sydney Consideration - What would be the aim of your assessment, since the diagnosis has been established? The University of Sydney Presentation 5 weeks later Progress: - Navicular fracture confirmed, patient spent 4 weeks NWB on boot. He was able to remove the boot for shower and ROM exs (keeping NWB), which he did not do very often (perhaps 2-3 times over that period). Removed the boot this morning and came to see you. - Feels pain and stiffness in the ankle/foot (now I/T, 6/10), has been keeping the leg elevated. - Agg: walking and moving the ankle/foot. - Easing: elevating the leg and not moving/WB. - No longer taking any pain killer, remains with 2 crutches. The University of Sydney Presentation 5 weeks later Observation - Static - Slight swelling on the right ankle/foot, no bruising present. - Dynamic - Standing: can weight bear full body weight on the right for about 5 sec (with increase in pain), weight shifted to the left leg. - Walking: avoiding right side, limping with reduced DF at heel contact and reduced PF at toe-off. - Stairs: using the rails to help when WB on the right side, not negotiating steps, weight shifting to left side. The University of Sydney  Chrisholm et al 2012 Presentation 5 weeks later Palpation - Pain around the navicular area and the TC joint. No other areas of pain or tenderness. AMT - Dorsiflexion R ankle: PA P2 5/10, 5 cm from toe to wall (measured with the lunge WB method). Left ankle pain free and 12 cm from toe to wall. - Eversion R ankle: PA P2 4/10, 40o (55o on the left ankle). PMT - Eversion and DF limited around the same range as AMT on the right side, with some pain (more in DF than eversion). The University of Sydney Presentation 5 weeks later Swelling - Figure of 8 R: 86 cm - Figure of 8 L: 78 cm PAM - TC joint AP R: PA 3/10, 1/3 movement (stiff +++) compared to left - TC joint PA R: PA 2/10, ½ movement compared to left - Subtalar medial and lateral R: PA 1/10, 2/3 movement compared to left The University of Sydney Presentation 5 weeks later Muscle strength - Calf muscles (Plantarflexors): 4 (incomplete) heel raises on R (20+ on L) - Dorsiflexors: 4/5 on MMT on R (5//5 on L) BMC Musculoskeletal Disorders - Evertors and invertors: 3+/5 on MMT on R (5/5 on L) Muscle length - Calf muscles (Plantarflexors): 11o DF on R (20o DF on L) Balance - Static (single leg stance): 5 sec eyes open on R (30+ on L) The University of Sydney Impairments Could also consider assessing ligament - Pain and swelling integrity in future sessions - Difficulty walking, stairs - Limited range of motion - Joint stiffness - Reduced muscle strength What would you prioritise? - Reduced muscle length - Reduced balance Consider that Michael has been off work for 5 weeks and needs to be fit and safe to return to return The University of Sydney Initial management - Active ROM exs → move the ankle in all directions (often) - Elevation, compression (tubigrip) - Normal walking pattern (heel-toe) and increase WBAT - Stretching calf (with towel) - Manual therapy (limited role, but can use) - Strengthening muscles (start with theraband) The University of Sydney Moving forward - Advance strengthening to more functional exs (i.e., single leg heel raises) - Balance (static, dynamic) - Motor control, including major proximal muscles (gluts, quads, hams) - Proprioceptive exs Masnad Health Clinic The University of Sydney Lower Extremity Review Ankle Magazine  [email protected] The University of Sydney