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CLINICAL ASSESSMENT TESTS LATERAL LIGAMENTS: ATFL Origin: Lateral malleolus of fibula...

CLINICAL ASSESSMENT TESTS LATERAL LIGAMENTS: ATFL Origin: Lateral malleolus of fibula Insertion: Talus CFL Origin: Lateral malleolus of fibula Insertion: Calcaneus PTFL Origin: Lateral malleolus of fibula Insertion: Posterior talus MEDIAL LIGAMENTS: SPRING/DELTOID LIGAMENT: Origin: Calcaneus DELTOID (DEEP) Insertion: Navicular Origin: Tibia Insertion: Talus DELTOID (SUPERFICIAL) Origin: Tibia Insertion: Navicular/calcaneus Test What does it How to perform the test Possible questions test for? ANKLE Acute lateral ankle sprains and chronic ankle instability Anterior ATFL instability What does ATFL do? Drawer Test Limits Inv and provides lateral stability How does injury to the ATFL occur? Usually Pf/Inv injury What other tests could be used? Talar tilt test Ottawa ankle rules to exclude fracture X-ray warranted if pain or bone tenderness in the posterior distal tibia or tip of medial malleolus X-ray warranted if pain or bone tenderness in the posterior distal fibula or tip of lateral malleolus Unable to WB immediately after the injury or for four steps in the emergency department Palpate medial malleolus/deltoid ligament region (they often get pain on medial ankle) Anterolateral ATFL instability Change in ROM in WB lunge test (knee to wall test) Drawer Test Chronic: star excursion test What is the Coleman clock test? Used in chronic ankle instability to help determine if cavus foot is Ff or Rf driven How would you manage acute lateral ankle sprains? POLICE: Protect Optimally Load Ice Compress Elevate Orthotic/tape/brace Talar Tilt CFL instability What does the CFL do? Test Limits Inv and provides lateral stability. How does this injury occur? Typically occurs with PF/INV injury What’s another test that could be used for this condition? Anterior draw test Anterolateral drawer test Knee to wall test How would you typically manage this condition? POLICE Orthotic/tape/brace Essentially Inv the calcaneus to stress the CFL Valgus tilt Deltoid/medial What does the deltoid ligament do? stress test ligament Limits Ev and provides medial stability instability How does this injury occur? Injury where the body rotates in the opposite direction Lateral ankle sprains MUCH What are we looking for in the valgus tilt stress test? more common Laxity What’s another test that could be used for this condition? Anterior draw with slight Pf and Abd stress applied Supination resistance test Activation of the FHL creating forefoot supinatus How would you typically manage this condition? POLICE and symptom driven (what’s tolerable?) Orthotic/tape/brace Essentially Ev the calcaneus to stress the deltoid ligament Neutral heel Deltoid spring What does the spring ligament do? lateral push ligament injury Stabilises the medial longitudinal arch test How does this injury occur? Secondary to Inv/Ev rotation injury Direct Ev trauma where foot is pinned to ground What’s another test that could be used for this condition? FHL creating forefoot supinatus Positive valgus tilt test and anterior draw test with slight Pf and Abd force applied Leg hanging off How would you typically manage this condition? end of plinth POLICE Orthotic/tape/brace SYNDESMOSIS LIGAMENT: LISFRANC LIGAMENT: Origin: Medial aspect of distal fibular Origin: Medial cuneiform Insertion: Lateral aspect of distal tibia Insertion: Base of 2nd metatarsal Test What does it How to perform the test Possible questions test for? Syndesmosis Squeeze test Syndesmosis What is this testing for? ligament For syndesmosis ligament injury injuries What does the syndesmosis do? Provides support during rotational activities How does this injury occur? Foot fixed in external rotation and Df while lateral force causes internal rotation of leg – open the syndesmosis anteriorly ATFL is typically injured first External Syndesmosis What’s another test that could be used for this condition? Rotation ligament Point test Stress Test injuries Heel thump test Hold around midfoot with thumb over medial side then produce ER of the foot Dorsiflexion Syndesmosis Test ligament injuries If the mortise widens, it indicates syndesmosis ligament injury Thump test Syndesmosis ligament injuries Point test Syndesmosis ligament injuries Lis Franc Piano Key Lis Franc What does the Lisfranc do? Test ligament injury Stabilises the arch for gait/toe-off Looking for pain How does this injury occur? and/or NON-CONTACT: Pf foot loaded by ground produces ER, Ev and Df of ankle and Pro of Ff instability CONTACT: Axial rotation injury that pushes foot into hyper plantarflexion  What are you looking for during the piano key test? Pain and/or instability of 1st and 2nd rays What is another test that could be used for this condition? Inability to propel off forefoot Double leg heel raises and single leg heel raise Provocation Lis Franc injury test Squeeze from both sides at base of metatarsals  PLANTAR PLATE INJURY: MORTONS NEUROMA: Insertion: Proximal phalanx Ligament that lies on plantar surface of MPJ’s Between 3rd/4th metatarsals Test What does it How to perform the test Possible questions test for? FOREFOOT INJURIES Plantar plate Dorsal Plantar plate What does the plantar plate do? Drawer test injury Primary stabilising structure of lesser MTP joints Helps maintain SP motion in MPJs How does this injury occur? Exposure to compressive loads prior to compulsion and tensile loading during propulsion What is this testing for? For plantar plate injury/tear What’s another test that could be used for this condition? Vulcan sign – 2nd toe deviating medially away from 3rd toe Active ROM Neuroma tests – thumb index finger squeeze test, Mulders test, foot squeeze test (in that order) Secure the midfoot dorsally and plantarly around the 2nd MPJ, and hold the 2nd toe How would you typically manage this condition? around the MPJ and apply pressure upwards Symptom driven (assess irritability) while distracting the joint Taping Lasoo  Padding – u-pad/metdome/swanfoam Custom orthotics Provocation Plantar plate test injury Df the 2nd toe and apply circular pressure at the plantar surface of the 2nd MPJ Pain indicates a positive test Digital Plantar plate plantarflexion injury test Apply pressure with thumb at the plantar surface of the 2nd MPJ and plantarflex the 2nd toe Looking for pain when Pf the digit, increase in Pf stiffness and possible lack of Pf ROM Neuroma Thumb index Morton’s How does this injury occur? finger test neuroma Due to compression and irritation of the nerves. Apply pressure with thumb and index finger in the intermetatarsal space, looking for pain Mulders click Morton’s test neuroma Df foot, squeeze metatarsals and apply pressure to plantar surface of foot with other thumb, lookings for audible click Squeeze test Morton’s neuroma Squeeze metatarsals together  ACHILLES INJURY: Origin: Gastroc/soleus muscle Insertion: Calcaneus Test What does it How to perform the test Possible questions test for? TENDONS Thompson Achilles tendon What does the Achilles do? test rupture Lifts heel off the ground (Pf) What is the Thompson test testing for? Achilles tendon rupture – if the foot Pf, the tendon is not ruptured What is the royal London hospital test testing for? Achilles tendinopathy – its present if symptoms reduce during Df and Pf What is the Arc sign testing for? To differentiate between tendon and peri-tendon – tendinopathy present if area of thickening moves with the tendon beneath your fingers during Df and Pf How does this injury occur? Forceful pivoting or running Positive Achilles Excessive compression and tensile loads Royal tendinopathy London What is the difference between insertional, midportion and sheath injury? Hospital Insertion injury occurs due to excessive compression and tensile loads test Midportion injury occurs due to excessive tensile loads Peritendinopathy (sheath) injury occurs due to friction loads, pain does not warm up, peritendon must be managed first before the tendon When are compressive and tensile loads produced? Compressive – when in ankle Df, e.g. pushing off from Df position, hanging heel off edge of step Tensile – when using the tendon like a spring, e.g. jumping, sprinting Combined compressive and tensile loads – e.g. pushing off in end range Df Friction – e.g. repetitive Pf and Df How would you typically manage this condition? 1. Activity modification Swelling in the tendon that is most painful 2. Education becomes less tender with maximal dorsiflexion 2. Gradual activity exposure indicates tendinopathy 3. Introduce more difficult activities Isometrics vs isotonic exercises Stretching and shortening cycles Arc sign Differentiate Night wrap tendon from peritendon If the thickened area does not move it means, there is sheath involvement as the sheath does not move → the tendon just moves within the sheath Test What does it How to perform the test Possible questions test for? BONE STRESS INJURY Calcaneal BSI What is this testing for? Squeeze BSI test How does this injury occur? Appear 3-4 weeks following a major workload “error” Bone resorption > bone formation What tool can be used to determine a female’s risk for BSI? RED-S Risk Stratification Tool How would you typically manage this condition? 1. Pain free gait Tenderness over calcaneus while squeezing the 2. Maintain aerobic fitness heel from both sides 3. Return to activity Navicular: N BSI 4. Osteogenic activities – resistance training → zigzag hopping (not – spot treadmill running) Do BSI ‘warm up’ during activity? No What BSI’s would you not use the hop test for? High risk BSIs – 5th metatarsal, sesamoids What are the low risk BSI’s? Calcaneus, cuneiform, cuboid Sesamoids: BSI Axial compression test Hop test BSI Excellent test for most BSI’s 100% sensitivity in tibial BSI’s Test What you need How to perform the taping Possible questions TAPING Hyperdorsiflexion 2 thin strips 1. Thin tape loosely around base of hallux What is turf toe and how does it occur? Injury – turf toe 7 medium sized strips 2. 5 strips from tape 1 down to heel (just where Injury to plantar structures of 1st MPJ the arch ends), going from lateral to medial by Occurs due to external force being applied to hyper Df 1st MPJ with starting on plantar surface elevated heel (external force could be running backwards and hitting 3. 2 strips to secure proximal end of tape at the pothole) heel from plantar to dorsal midfoot 4. Thin tape loosely around base of hallux to Why would you do this taping? secure Used in turf toe to restrict the excessive Df of the hallux Provides Pf and Abd force to 1st MPJ How would you manage turf toe? POLICE Taping Stiff soled shoe Orthotics Hyperplantarflexion 2 thin strips 1. Thin tape loosely around base of hallux What is sand toe and how does it occur? Injury – sand toe 5 medium sized strips 2. 5 strips from tape 1 down to heel (just where Occurs due to external force being applied to hyper Pf 1st MPJ with the arch ends), going from lateral to medial by elevated heel (external force could be running in sand, kicking ground) starting on dorsal surface 3. 2 strips to secure proximal end of tape at the Why would you do this taping? heel, going from plantar to dorsal midfoot Used in sand toe to restrict the excessive Pf of the hallux 4. Thin tape loosely around base of hallux to Provides Df and Abd force to 1st MPJ secure How would you manage sand toe? POLICE Taping Stiff soled shoe Orthotics Digital 1 thick strip 1. 2 strips hypafix around 2nd toe to create a What is this taping used for? Plantarflexion 2 thin strips of hypafix cancer ribbon to cause plantarflex Plantar plate injury (plantar plate) 2. Secure with thick strip Provides Pf force to reduce force during propulsive phase of gait Taping Standard ankle 1. Anchor strip around ankle just above Achilles What is this taping used for? taping with heel tendon Stability, support, compression in ankle instability lock 2. Under heel up to anchor strip Prevent re-injury 3. Same thing but finish slightly more anteriorly Ankle ligament sprains 4. Same thing but finish slightly more posteriorly Tendinopathies 5. Figure of 6 – start at medial ankle and go under heel up and around to finish in same spot 6. Figure of 6 – start at lateral ankle and go under heel up and around to finish in same spot 7. Heel lock – start anterior ankle, go behind heel on Achilles tendon, wrap back around heel and finish in similar spot to starting position 8. Heel lock – in other direction 9. Secure with another strip around the ankle above Achilles tendon Low-dye taping 1. Anchor strip going horizontal under 1st to 5th What is this taping used for? met head Medial arch support 2. Anchor strip from 1st to 5th met head around Plantar heel pain back of heel on Achilles tendon Ankle ligament sprains 3. 3 vertical strips from met heads to under heel Tendinopathies (one in middle one lateral one medial) 4. 5 or so overlapping horizontal strips from lateral to medial, first under Mets and last on heel 5. Secure the same as anchor strip  6. Secure dorsally with one loose strip Heel compression 1. Start above heel on medial side, around back What is this taping used for? of heel and finish on lateral side Plantar heel pain OR 1. 3 overlapping horizontal strips 1st at heel then going towards toes 2. Secure with strip around back of heel  LOAD MANAGEMENT, REHABILITATION AND EXERCISE PRESCRIPTION Introduction to managing the athlete Load management and return to activities Goals Client goals – what they want to achieve from us Therapeutic goals Physiological and/or psychobehavioural changes we are seeking from our interventions, in order for our client to achieve their goals o Our WHAT to achieve their WHY Load Stressors applied to tissues/organisms  Yellow flags include: Beliefs Loss of control Pain catastrophising Kinesiophobia (fear avoidance) Anxiety Low self-efficacy Coping strategies Familial factors Before we can manage load, we need to know: o The loads a person is being exposed to o The load-tolerating capacity the person has Not every clinical presentation is purely a physical problem o ie: We may have two clients both presenting with plantar fasciopathy or Achilles tendinopathy, one may be very much load-based injury and one may be driven by psychobehavioural mechanisms Assessing load exposure and load tolerating capacity Subjective history o Need to understand the patients agenda for their visit - Beliefs - Fears - Motivators - Barriers o Enables assessment planning, treatment planning and goal setting - Identify suitable clinical assessments - Triage priorities for therapeutic interventions - Suitable interventions o Ensure patients wants, needs and preferences are identified and they are educated and supported to participate in their own care o Information we need: - Symptoms - Onset - Duration  - Exacerbating/alleviating factors - What CAN they do - What CAN’T they do - Previous treatment(s) – what worked, what didn’t Pay attention to WHAT they say and HOW they say it, and WHAT they move and HOW they move o Pathology drivers: - Physical vs psychological drivers of pain – may influence: Your management approach Treatment narratives Therapeutic interventions Timing of introducing treatment interventions Need to alter/change management approach Outcome measures – including patient reported outcome measures (PROMS) o PROMS: - Captured via questionnaire - Identify patients perception - Disease specific or generic - Free of clinician/outside interpretation Examples include American Orthopaedic foot and ankle score (AOFAS), foot and ankle disability index (FADI), foot function index (FFI) Yellow flag screening tools can include chronic pain acceptance questionnaire revised (CPAQ-R) and pain catastrophising scale o Clinician reported measures: - Completed by healthcare professional - Has clinical judgement involved o Performance based measures: - Client performs set of movements or tasks - Scores based on objective or qualitative metrics Functional tests may include:  o Observer reported measures - Completed by someone who regularly observes client on a frequent/daily basis Objective assessment Functional assessment Physical load Physiological loading = moving within our load tolerating capacity Non-physiological loading = exceeding our load tolerating capacity or doing too little and decreasing our capacity Need to understand their PAST & CURRRENT load exposures Positive adaptation Negative adaptation (excess load → injury) Negative adaptation (insufficient load → reduced capacity) Summary “Go slow to go fast” o Take time to gather relevant info to a devise a management plan that is individualised, goal-orientated and meaningful o Identifying client goals is important to improve treatment adherence o Identifying therapeutic goals is important to understand what your therapeutic interventions will achieve o Select some outcome measures so you know if there are changes in symptoms or functional movements (getting better, worse or no change) o Have a plan → what are you working towards Rehabilitation & Exercise Prescription Why injuries NEED movement MSK injuries develop due to applied load > tissue capacity Acute injuries – single instance of tissue overload and/or short duration of sub-optimal tissue environment Chronic injuries – prolonged exposure to pathological loads and/or extended periods of sub-optimal tissue environment Movement is essential for triggering correct cellular responses required for healing/adaptation o Movements required for triggering cellular responses vary from person to person - For some, we may need to ADD load - For others, we may need to SUBTRACT load Formulating your rehabilitation/exercise program 1. What are the clients goals? What are the desired activities / desired functional capacity? 2. What is the function of the tissue/structure? How does the tissue need to function in the desired activities? 3. What impact do --- factors and/or --- pathology have on the tissue/structure? Are there any psychobehavioural elements present? 4. What is the current functional capacity of the tissue/structure? What current load-tolerating deficits are present? → therapeutic goals → exercise selection → program development and implementation Why prescribe exercise and movement? Injury management → collagen synthesis and endurance o Achilles tendinopathy o Plantar heel pain Injury risk reduction → muscle mass and hypertrophy o Tendinopathies o Stress fractures Performance → neuromuscular power o Sprint performance o Running economy (RE) Adherence to exercise plans People’s expectations are: Pathology → exercise rehab → success but really progress is not linear Factors that influence adherence: Self efficacy Threats and beliefs Locus of control Pain Physical activity Psychological symptoms Social support Perceived barriers Approaches that can improve adherence: Coaching Goal setting Self-monitoring Education Digital support (eg automatic reminders) Rehabilitation programming Key concepts/terminology Clinical decision making for exercise prescription Effective therapeutic exercise prescription requires 1) Assessing patients current status (ie current capacity) 2) Determining appropriate, relevant and achievable goals (ie to achieve the desired capacity) The goal is the close the gap between current performance and the patient’s goals or capacity To do this, need to make decisions relating to: o Identify involved/injured tissues o Identify stage of tissue healing and irritability (reactivity) o Determine appropriate criteria and timing for exercise progression o Understand contextual factors o Understand specificity and dosage principles Types of exercise/movement Stretching Introducing a stressor/load in gradual manner to allow MSK system to progressively adapt Isometrics Specific adaptation to imposed demands Exposing the MSK system to a stressor to create a specific adaptation to facilitate a function Muscle remains same length against load Isotonic (concentric and eccentric) Frequency, intensity, time, type Muscle shortens and lengthens against load Plyometrics Ability to apply force during a movement Power Force x velocity Exercise/movement dosage Exercise selection and dosage for pain vs performance may be different – some patients may just need to return to activity, whereas some may have specific performance goals or need to return to high level performance ie it will look different for everyone Exercise selection + exercise dosage = tissue response Dosing WITHOUT sets and reps AMRAP = as many repetitions as possible Can use AMRAP for time or AMRAP relative to the traffic light system Selecting exercises Need to consider: Desired activities/movements (ie desired capacity) Current capacity Do we need to ADD or SUBTRACT load? Do we need to go general or specific? The individual and the adherence factors (beliefs, fears, available time, preferences etc) Access to equipment and support Essentially… consider what they can do vs what they can’t do and what interventions they need to bridge the capacity gap Progressing vs regressing Regress Too complex Adverse response Unable to perform movement safely Progress Too easy/not feeling enough load Achieved desired number of sets/reps Plateau of functional improvement  Pain symptoms improved (+ functional improvements) How to regress Reduce dosage Sets, reps, range, tempo, resistance, frequency etc… Change exercise How to progress Increase dosage Sets, reps, range, tempo, resistance, frequency etc… Change exercise PLANTAR FASCIOPATHY Plantar fascia Origin: medial calcaneal tubercle Insertion: bases of proximal phalanges of all digits Fibres arranged mostly longitudinally that form crimp like waves that elongate under load Core: high % type I collagen and low % type IV collagen Sheath: opposite to core Gait and function Longitudinal arch lowers and lengthens during stance Absorbs loading forces (energy) during heel strike Releases energy during heel off → allows propulsion Plantar fasciopathy Degenerative process, little to no inflammatory markers Caused by repetitive stress and individual risk factors Histopathological findings: o Changes in appearance of tissues  o Calcification o Absence of active inflammation Pathomechanics (causes/risk factors) Foot types (high/low/normal) Ankle Df ROM o Reduced Df during stance phase may lead to compensatory increase in midfoot dorsiflexion o Anatomical relationship with Achilles tendon can increase plantar fascial load Muscles – weakness of intrinsic and extrinsic foot muscles eg tib post and fibularis longus, and hamstrings/quadriceps Clinical decision making framework: Education o About condtion o Prognosis o Evidence based treatments Stretching o Assess individual, type of stretching may vary Taping o Load modification o Think of the individual – are orthoses more suitable (tape allergy etc) Load management o Activity modification  o Build load capacity o Footwear o Heel lifts Pain education o Fear avoidance, catastrophising etc Related conditions o External referrals? Footwear o Heel offset, heel-forefoot rocker, midsole etc. Exercise therapies Only patients with an identified capacity gap need a rehab program Load exposure o Do we need to decrease load and increase recovery time, or do we need to increase load and decrease time between load exposure? o Too much = losing capacity o Not enough = losing capacity Connective tissue responses to load How to know if someone needs prescribed exercises? Consider multiple factors Capacity gap that is unlikely to be bridged from load modification and management? Underlying factors that will continue to perpetuate the injury? Potential adverse functional deficits? Summary Not all patients with plantar fasciopathy require prescribed rehabilitation programs Progressive movement exposure may be all your ‘rehabilitation program’ requires Consider what loads need addressing: o Load modification: load management/education, strapping, footwear, orthoses o Load re-introduction and capacity building: load exposure, prescribed exercises, both? Assess short term and long-term movement history to guide if you need to calm things down or build things up Identify what client wants to do, then assess what they can do, then build management plan Types of exerecises will depend on their desired capacity o Consider frequency, velocity, range and duration o If movement is low velocity (eg walking) you ‘dose’ may reflect this o If movement is high velocity (eg running) you may need to program a higher ‘dose’ TENDINOPATHY Management Patient education o About the condition o Prognosis o Pain education o Addressing psychological factors Loading advice o Reducing provoking activites o Increasing non-provoking activities o Gradual increase in load o Use pain scale to monitor activity exposure Active treatment o Progressive strengthening for at least 12 weeks o Exercises should be individualised based on needs and presentation Individualised management Tendons Physiology and function Gliding tendons (eg Tib post tendon) o Change direction around bony prominence/pivot point o Higher levels of compressive forces at osseous interface o Regions of tendons have increase fibrocartilage and are more hypo vascular Traction tendons (eg Achilles tendon) o Direction of pull is in line with direction of muscle Stiffness vs compliance Stiffness (rigidity) o Resistance to elastic deformation when force is applied o Hard to distort o Stiff materials have high modulus of elasticity (substantial stress required to minor deformation) Compliance (flexibility) o Tolerance to elastic deformation when force is applied o Easily stretched or distended  o Compliant materials have low modulus of elasticity (minor stress required for substantial deformation) Tests – Achilles tendinopathy Diagnostic tests – help identify presence of pathology Functional/loading tests – help assess clients level of function to help set functional goals and guide treatment Exercise rehabilitation Do we need to ADD or SUBTRACT load? o Alter load via orthoses or footwear o Deload via activity modification o Add load via dosage to progress towards goal capacity How to know if someone needs prescribed exercise? o Capacity gap that is unlikely to be bridged from load modification and management? o Underlying factors that will continue to perpetuate the injury? o Potential adverse functional deficits? Summary Not all patients will require prescribed rehabilitation exercises o Progressive movement exposure may be all your ‘rehabilitation program’ needs Consider the loads you need to address and introduce to your client o Tensile vs gliding tendons o Load modification: load management/education, strapping, footwear, orthoses o Load re-introduction and capacity building: load exposure, prescribed exercises Assess short term and long-term movement history to guide if you need to calm things down or build things up Identify what client wants to do, then assess what they can do, then build management plan Types of exercises will depend on desired capacity o Consider frequency, velocity, range and duration o If movement is low velocity (eg walking) you ‘dose’ may reflect this o If movement is high velocity (eg running) you may need to program a higher ‘dose’ ANKLE SPRAINS AND CAI Lateral ankle sprain Mechanism of injury o Inv + IR loading +/- SP positioning o Most non-contact LAS occur during jump landings, multidirectional running and sudden changes of direction Structures o ATFL (most common) o CFL o PTFL (least common) Risk factors o Previous history of LAS o Body composition – low and high BMI o Muscle strength o Postural control/balance Ottawa ankle rules – to exclude fracture A) Bony tenderness along distal 6cm of posterior edge of fibular and or tip of lateral malleolus B) Bony tenderness along distal 6cm of posterior edge of tibia and or tip of medial malleolus C) Bony tenderness at base of 5th met  D) Bony tenderness at navicular Management RICE NSAIDs Immobilisation Functional treatment (functional support and exercise) – functional support = ankle brace/taping Manual mobilisation Surgical intervention Adjunct therapies – acupuncture, ultrasound, laser, shockwave Prevention – functional support, exercise, footwear Prognosis Pain, recurrent sprains and instability for years common Anterior impingement in 25% Up to 40% will develop chronic ankle instability (CAI) Chronic ankle instability Mechanical instability Functional instability Recurrent sprains +/- pain +/- swelling Ankle sprain clinical impairments Ankle ROM Ankle strength Acute ankle injury functional assessment – ankle functional scale and sport ankle rating system Chronic ankle injury functional assessment – CAIT, FAAM, FADI Dynamic postural control – SEBT, multiple hop test Proprioceptive deficits Neuromuscular deficits Gait alterations Walking – CAI less Df during gait cycle Jogging – CAI more Pf and Inv Rehabilitation planning Example clinical journey – LAS (Grade 1 – low grade 2) Example clinical journey – CAI Summary Even low grade LAS require functional restoration to reduce risk of CAI Consider mechanism of injury to identify structures affected Don’t forget to consider syndesmosis injuries Consider the common functional impairments caused by LAS and CAI o Sagittal ROM, proprioception, sensory motor function, muscle strength, performance tests Types of exercises required depend on their desired activities For CAI you will likely require higher frequency and dose (repetition) to address neuromotor deficits/impairments Assessment and treatment of MSK injuries Injury/ History Physical examination Clinical tests Imaging Management condition ANKLE AND FOOT LIGAMENT INJURIES Acute lateral Incident of Ottawa Ankle Rules to exclude fracture Anterior drawer test CT scan indicated in Initially ankle sprain landing or Palpate medial malleolus/deltoid coalitions and POLICE (protect, trauma that ligament region (medial ankle pain and suspected bony optimally load, ice, results in ankle deltoid lesion common) avulsions compress, elevate) Inv/Inv + Pf Anterior draw test for ATFL instability Avulsion at origin Identify painful Talar tilt test for ATFL/CFL instability of bifurcate 2-4 weeks palpatory spot, Reduced ROM in WB lunge test (or ligament jointing Boot/brace can WB, increased) – knee to wall test the antero-superior Air cast walker minimal In clinical practice, only difference calcaneus to ASO oedema → between simple sprains (grade 1) and navicular and likely no real instability (grade 3) is relevant cuboid 4-8 weeks ligament o Grade 1 – minor swelling and Orthotics rupture palpatory tenderness, minimal Lateral instability Large oedema, functional loss, no increased (ATFL/CFL)– had to stop instability Lateral Ff sport, o Grade 3 – severe bruising, wedge ecchymosis swelling and pain, significant Talar tilt test Mortary pad (bruises) → loss of function, increased High lateral high chance of instability, unable to WB and heel cup ligament walk normally Plantar EVA rupture lateral arch fill Chronic Repeated Anterolateral/anteromedial ankle joint Cuboid notch lateral ankle episodes of tenderness on palpation Lateral skive sprains LAS Reduced ROM in WB lunge test to correct Rf Patient Positive anterior draw test and talar tilt Ev reported test Medial instability mechanical Assessment of midtarsal ligaments is (deltoid/spring) – and critical – dorsal CCJ, bifurcate, dorsal High medial psychological TNJ and spring ligaments heel cup/ weakness Biomechanical assessment – cavovarus medial flange Presence of foot type, NWB Inv bias, rigid Pf first Medial EVA pain along ray, Ff valgus filler anterior ankle o Coleman block test – tests if Medial heel joint with cavovarus foot is Ff or Rf skive swelling post driven 1-4 Ff varus activity wedge  o First ray off edge – if calc. goes Ankle taping to neutral → Ff driven, if calc. Standard remains Inv → Rf driven ankle taping Reduced reach in Star Excursion Test with heel lock Anterior ankle Anterior ankle Anterolateral/anteromedial ankle joint Dorsal impingement sign X-ray in lateral view Ankle taping impingement pain in Df tenderness to assess extent of heel lock + demanding Reduced ROM in WB lunge test bony spurring medial STJ activities with Pain during single or double leg squat MRI to observe bias reduced Positive dorsal impingement sign (pain marrow oedema, Low dye mobility in last picture to the right because subchondral taping History of you’ve recreated the impingement like changes and Medial/lateral recurrent LAS in WB) synovial/soft tissue variation of Presence of thickening low dye pain along taping anterior ankle Ankle brace joint with swelling post activity Posteromedial Persistent Palpable tenderness behind medial MRI ankle isolated malleolus, deep to tib post tendon Coronal PD shows impingement posteromedial Pain with passive posteromedial digital scarring (POMI) ankle pain pressure with ankle Pf/Inv Interpod non-custom related to No pain during palpation with resisted device activity and activation of tib post tendon Custom device dating back to o Tensing tib post tendon Richie Brace an Inv injury protects site of deep Initial lateral posteromedial tenderness ankle from palpation symptoms Nil symptoms of TP, FHL or FDL following Inv injury Insidious onset 8+ weeks of Orthotic/brace posteromedial Consider orthopod and medial review if activity related conservative fails pain typically after 6 months after 4-6 May require brace weeks but can for increased be longer demands for 1-2 Syndesmosis Mechanism of Pain with passive ER/Df Squeeze test years injury injury:  Foot in fixed Reproduction of pain in any positive position of ER Point Test, squeeze test, ER stress test, and ankle Df Df test, heel thump test while a lateral Early heel rise gait pattern to avoid force at trunk painful Df range as well as push off pain or hip causes IR of lower limb (fibular in ER stress test ER while tibia goes into IR) ER rotation trauma with pain at syndesmosis that may extend Df test proximally Inability to WB and swelling Pain with active/passive ER or Df of foot/ankle Thump test Point test Deltoid Mechanism of NWB pain with palpation along Valgus tilt stress test Standard WB x-rays ligament injury: anteromedial gutter – shows structural injury (medial Crush damage Laxity present during valgus tilt stress changes and instability) secondary to test excludes bony repeat LAS Positive anterior draw test with slight Pf pathologies High intensity and Abd stress o Ev stress movement Valgus tilt stress test, neutral heel AP while body lateral push test radiograph simultaneously WB asymmetrical planus or Rf valgus to rotates in o Correction of Rf evaluate opposite valgus/pronation during DL stability direction calf raise (activation of tib Anterior draw test Coronal MRI – (dancing, post) shows interstitial running, o Gradual increase in Rf tearing/contusion downstairs, valgus/pronation during DL through deep uneven squat (activation of FHL deltoid fibres surface) creating Ff supinatus during Direct Ev WB supination) trauma where Supination resistance test foot cannot o How much force you need to escape (pinned apply to resist pronation and to ground) product supination (two fingers on medial arch) – low History of score = easy to supinate symptom onset after above Neutral heel lateral push test mechanism of injury Acute: injury, local pain, swelling Chronic: patient reports ‘giving way’ feeling Patient reports pain around anteromedial ankle and sometimes lateral ankle,  particularly during loaded Df Spring Mechanism of Injury is secondary to rotational ankle injury Standard WB x-rays ligament injury: (Inv/Ev sprains) or post tib tendon – shows structural (mostly all High intensity dysfunction so assessment should be in changes and similar to movement context of these other pathologies excludes bony deltoid while body NWB pain with palpation along pathologies ligament simultaneously anteromedial gutter o Ev stress injury) rotates in Possible laxity present during valgus tilt AP opposite stress test radiograph direction Possible positive anterior draw test to (dancing, with slight Pf and Abd stress evaluate running, Possible positive neutral heel lateral stability downstairs, push test Coronal MRI – uneven WB asymmetrical planus or Rf valgus shows interstitial surface) o Correction of Rf tearing/contusion Direct Ev valgus/pronation during DL through deep trauma where calf raise (activation of tib deltoid fibres foot cannot post) escape (pinned o Gradual increase in Rf to ground) valgus/pronation during DL Progressively squat worsening flat o Navicular drop/drift foot deformity o Supination resistance test o Jacks test History of o Activation of FHL creating Ff symptom supinatus during WB onset after supination mechanism of injury above Acute: injury, local pain, swelling Chronic: patient reports ‘giving way’ feeling Patient reports pain around anteromedial ankle and sometimes  lateral ankle, particularly during loaded Df Injury/ History Physical examination Clinical tests Imaging Management condition MIDFOOT & FOREFOOT INJURIES Lisfranc Mechanism of Motor examination of all tendons in midfoot Piano key test WB x-ray – ligament injury: Palpable tenderness of 1st/2nd TMTJ standard AP, injury Axial and/or Pain and/or instability with Piano key test of 1st and oblique, (tarso- rotational 2nd rays lateral metatarsa (Abd) load Pain with midfoot compression (Provocation test) + l joints) applied to a Pf dorsal and plantar flexion of the 1st met head Must be WB foot relative to 2nd met head as it creates An axial force DL heel raise, SL heel raise for pain and ability stress through results in If they can perform both these with minimal pain foot and can hyper-Pf of the and loss of function → not an unstable injury more foot, causing consistently tension failure identify of the weak presence of dorsal instability ligaments Pain in the midfoot after some form of trauma/injury May be able to recount the exact mechanism Some generalised swelling mostly over midfoot Plantar ecchymosis may be present depending on how acutely the patient  presents (in Provocation test chronic cases, need to ask if this was present) Patient may report inability to propel off Ff Midfoot Localised pain Passive and active examination of NWB x-ray may 0-4 weeks OA and movements – assess for asymmetry and irritability show reduced Assess irritability tenderness, Motor assessment of tendons with and without joint space, Identify tissue involved joint stiffness, resistance osteophytes, Gauge level of intervention required bony Midfoot varus/valgus stress tests, piano key test soft tissue (footwear, orthoses) enlargements WB: A more flatfoot posture, lower medial swelling, Educate patient on timeline Patient may longitudinal arch and greater midfoot loading subchondral Implement strategy report history Greater calcaneal Ev during stair ascent sclerosis Taping of previous (propulsion) Rocker bottom footwear trauma to the Increased plantar pressures + contact times in heel Carbon fibre plate joint or and midfoot – reduced Ff rocker ASO proximal ankle Functional hallux limitus test, Jacks test, supination 4-12 weeks joint resistance test Orthoses Pain localised 1st MPJ OA – consider 1st ray function: to dorsal Reduce motion → Morton’s and/or medial extension aspects of Increase motion → 1st ray cut midfoot – out worsens with Material consideration tasks requiring Moderate STJ and midtarsal greater pronation propulsive Midfoot OA – consider irritability of foot: forces to be Cushioning important  generated such Contour to midfoot important as stair ascent but consider too much pressure or propulsive Moderate STJ/midtarsal phase of gait pronation 1st MPJ Pain in 1st MPJ Get baseline measure of irritability and tolerance Shoe stiffening insert (carbon fibre plate) OA >25 months to WB or stiff shoe Patient may NWB examination: dorsal exostosis, 50% 2. Education Explain why we do activity modification and gradual activity exposure  Optimal loading for tendons = pain 2- 4/10 3. Graded exposure Grade activities based on perceived apprehension and patient reported pain Progress by increasing activity difficulty (eg add external load) Phase 1 – isometric: o Start here if isotonic load unacceptably painful (loading and holding static at tolerable range) Phase 2 – isotonic: o Should be starting point if tolerable (going through full range) Phase 3 – stretch/shortening: o Introduce stretch/shorten cycles such as walking and running 2-3 times / week with rest days in between o Load should be guided by pace or step count Understand type of load irritating the tendon →  reduce/remove the magnitude of that load Tibialis Localised pain on Tendinopathy (warm up effect) 0-6 weeks posterior medial side of Pronated foot type Step 1: tendinopathy/ midfoot to Rf Sore during, but able to perform, SL heel raise Assess pain intensity and tenosynovitis and/or ankle The following may be present: behaviour with usual Aggravated by o Tenderness on palpation activities activities that o Swelling along the tendon Understand level of increase tendon o Poor Pf Inv strength tendon irritability loading (walking, Tenosynovitis (no warmup effect) Determine tissue driving running, Pronated foot type symptoms (tendon or plyometrics) Sore/restricted during lunge test sheath) Natural history is Sore during, but able to perform, repeated SL heel Treatment goal slow, with raise Return pain to 1-3/10 insidious onset of The following may be present: during ADL complaints o Tenderness on palpation Reduce Warms up with o Swelling along tendon inflammation/swelling in activity only to be sheath worse the next Increase tendon day → strength/compliance tendinopathy Treatments Worsens with Activity modification to continued remove/modify loading or provocative loads activities taking Anti-inflammatory (the the tendon night wrap for sheaths – through range → diclofenac gel, hirudoid tenosynovitis cream, gauze, glad wrap) (sheath) Period of support/immobilisation (orthoses, ASO, taping) 6+ weeks Step 2: Graded exposure to load – isometric → isotonic → energy storage/release Treatment goal Return pain to 1-3/10 during ADL  Increase muscle/tendon strength/capacity Graded intro of stretch- shorten cycle activities based on agreed goals Treatments Footwear Orthoses Rehab Taping Standard ankle taping with heel lock Ankle taping heel lock + medial STJ bias Low dye taping Medial variation of low dye taping Orthotics High medial heel cup/medial flange Medial EVA filler Medial heel skive 1-4 Ff varus wedge Exercises Stretching isometric – ankle inversions with resistance band Isotonic – heel raises with Inv bias Walking/running depending on goals Posterior Persistent pain Stage 1 PTTD: Stages 2-3 tibial tendon on medial side of Tenosynovitis symptoms 0-2 months dysfunction midfoot to Rf Possibly sore/restricted during lunge test Step 1: and/or ankle with Sore during but able to do repeated SL raise Assess pain intensity and reports of a No rigid but possible subtle/flexible flat foot behaviour with usual progressively deformity activities worsening flat Stage 2 PTTD: Understand level of foot posture The following may be present: tendon irritability  No warm up Tenderness on palpation Determine level of tissue effect Swelling along tendon involvement – tendon, Age 50+ and Poor Pf Inv strength sheath, ligament, bone obese Laxity during valgus tilt stress test Reduce inflammation Positive anterior drawer test with slight Pf/Abd and daily pain levels stress Treatment: 2a: Activity modification to Flexible Rf valgus, normal Ff remove/modify Unable to perform SL heel raise provocative loads 2b: Anti-inflammatories (the Flexible Rf valgus, Ff Abd night wrap) Unable to perform SL heel raise Period of Sinus tarsi pain support/immobilisation Stage 3 PTTD: – taping, AIRCAST Flatfoot deformity, rigid Ff Abd, rigid Rf valgus walker, ASO Unable to perform SL heel raise Severe sinus tarsi pain (a sign of STJ involvement) Step 2: STJ involvement Graded exposure to load Stage 4 PTTD: Treatment goal: Flatfoot deformity, rigid Ff Abd, rigid Rf valgus Return pain to 1-3/10 Unable to perform SL heel raise during ADL Severe sinus tarsi pain (a sign of STJ involvement) Increase muscle/tendon STJ/ankle joint involvement strength/capacity but will be limited Graded intro of load Treatments: Footwear – stiff sole, rocker style Orthoses Richie brace Stages 3-4 Require surgery consultation with orthopod Peroneal Patients typically Palpation: recognisable tenderness over peroneal 0-2 months tendinopathy/ present with tendon/insertion, crepitus, swelling Step 1: tenosynovitis lateral ankle pain Passive Pf + Inv / Df + Ev often exacerbate pain Assess pain intensity and or pain along Muscle weakness compared to other side behaviour with usual course of WB assessment: activities peroneal tendons o Cavovarus foot type  that worsens o Ff or Rf driven cavus Understand level of with activity o RCSP Inv, Pf 1st ray, Ff valgus, laterally tendon irritability Acute injuries deviated STJ axis Determine level of tissue often reported as Any significant deformity worthwhile sending for involvement – tendon, ‘an ankle sprain imaging (ultrasound or MRI) sheath, ligament, bone that never o Determine resolved’ pathological Swelling, presentation – tenderness, acute, chronic, possible warm up tear effect, feeling of Reduce inflammation weakness/giving and daily pain levels way Treatments: Activity modification to remove/modify provocative loads Anti-inflammatories (the night wrap) Period of support/immobilisation – taping, ASO, wedging or orthoses Step 2: Graded exposure to load Treatment goals: Return pain to 1-3/10 during ADL Increase muscle/tendon strength/capacity but will be limited Graded intro of load Treatments: Footwear – neutral option, or customised from cobbler who can add extrinsic lateral wedging Orthoses – reduce supination moments and create extrinsic  peroneus longus moments Richie brace – lateral Orthoses Lateral Ff wedge, morarty pad High lateral heel cup, plantar EVA lateral arch filler Cuboid notch Lateral skive, cast corrected to x Ev degrees Injury/ History Physical examination Clinical tests Imaging Management condition BONE STRESS INJURIES BSI Diagnosis Low risk BSI Calcaneal squeeze test Running is poor at bone building Usually occur because NWB: Tenderness that is readily Multidirectional load vital for bone strength of a training load error palpated at subcutaneous sites (met Weekly running shaft, posteromedial tibia, anterior volume can be tibia) misinterpreted and Swelling, redness, heat over injured underestimate training site stress → use other NWB clinical tests variables such as time o Calcaneal squeeze test and sRPE (session rate o ‘N’ spot (navicular) of perceived exertion) o Metatarsal load test RED-S Risk o Axial compression test Stratification Tool (sesamoids) Ff BSI o Low body WB clinical tests Navicular ‘N’ spot Step 1: Pain free gait (0/10) weight due to o Hop test Create pain free status in bone – disordered footwear, carbon plate, AIRCAST, eating crutches o Low BMI Establish training history/load error or o Irregular internal risk for BSI periods Understand what you are getting the patient back to  o Delayed Understand foot type – menarche pronated/supinated o Low BMD Imaging if required o Previous Step 2: Maintain fitness stress injury Aerobic fitness through cross training activities Low risk BSI Modify loading on injured region – Posteromedial tibia footwear, foot positioning Distal 1-4th met shafts Swimming, cycling, deep water running, Calcaneus ski erg Distal fibula Combine HIIT and endurance Cuboid