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Chapter 5Chapter 5
The Ankle and Lower Leg The Ankle and Lower Leg ContinuedContinued
Stress FracturesStress Fractures
Evaluation FindingsEvaluation Findings Table 5-9, page 169Table 5-9, page 169
Predisposing factorsPredisposing factors Narrow tibial shaft, hip external rotation, pes Narrow tibial shaft, hip external rotation, pes
cavuscavus Diagnostic testingDiagnostic testing Bump Test (Box 5-9, page 170)Bump Test (Box 5-9, page 170) Treatment (Figure 5-26, page 169)Treatment (Figure 5-26, page 169) Table 5-10, page 171Table 5-10, page 171
Os Trigonum InjuryOs Trigonum Injury Evaluation FindingsEvaluation Findings
Table 5-11, page 173Table 5-11, page 173 Steida’s process (figure 5-27,page 172)Steida’s process (figure 5-27,page 172)
Formation of an os trigonum (Fig 5-28, p172)Formation of an os trigonum (Fig 5-28, p172) Os trigonum syndrome (talarcompression Os trigonum syndrome (talarcompression
syndrome)syndrome) Inflammation of posterior jointInflammation of posterior joint Inflammation of surrounding ligamentsInflammation of surrounding ligaments Fracture of the os trigonumFracture of the os trigonum Pathology involving Steida’s processPathology involving Steida’s process
Os Trigonum Injury cont.Os Trigonum Injury cont.
Inversion/plantarflexion Inversion/plantarflexion posterior talocalcaneal ligament tightens posterior talocalcaneal ligament tightens
against os trigonum or Steida’s processagainst os trigonum or Steida’s process Eversion of calcaneus Eversion of calcaneus
os trigonum or Steida’s process to become os trigonum or Steida’s process to become compressed between tibia and calcaneuscompressed between tibia and calcaneus
TreatmentTreatment
Achilles Tendon PathologyAchilles Tendon Pathology
Association with gastrocnemius and Association with gastrocnemius and soleussoleus
Decreased plantarflexion strengthDecreased plantarflexion strength Changes in gait; ability to walk, run, jumpChanges in gait; ability to walk, run, jump
Achilles TendinitisAchilles Tendinitis
Evaluation FindingsEvaluation Findings Table 5-12, page 174Table 5-12, page 174
Poorly vascularized structurePoorly vascularized structure Limited blood supply - posterior tibial arteryLimited blood supply - posterior tibial artery Distal avascularized zone – 2 to 6 cm Distal avascularized zone – 2 to 6 cm
proximal to insertion on calcaneusproximal to insertion on calcaneus Delayed healingDelayed healing
Achilles Tendinitis cont.Achilles Tendinitis cont.
ParatenonParatenon Highly vascularized structure, surrounds Highly vascularized structure, surrounds
tendontendon PeritendinitisPeritendinitis TendinosisTendinosis
Degeneration of tendon’s substanceDegeneration of tendon’s substance Peritendinitis Tendinosis Tendon Peritendinitis Tendinosis Tendon
RuptureRupture
Achilles Tendinitis cont.Achilles Tendinitis cont.
Factors leading to achilles tendon Factors leading to achilles tendon pathologypathology Tibial varumTibial varum CalcaneovalgusCalcaneovalgus HyperpronationHyperpronation Tightness of triceps surae, hamstring groupsTightness of triceps surae, hamstring groups Running mechanics, duration and intensity of Running mechanics, duration and intensity of
running, type of shoe, running surfacerunning, type of shoe, running surface Biomechanics of foot and ankleBiomechanics of foot and ankle
Acute OnsetAcute Onset
Achilles Tendinitis cont.Achilles Tendinitis cont.
Age and genderAge and gender Pain characteristicsPain characteristics Treatment/Return to activityTreatment/Return to activity
Achilles Tendon RuptureAchilles Tendon Rupture
Evaluation FindingsEvaluation Findings Table 5-13, page 176Table 5-13, page 176
Forceful, sudden contraction = large Forceful, sudden contraction = large amount of tension developing in tendonamount of tension developing in tendon
TheoriesTheories Chronic degeneration of tendonChronic degeneration of tendon Failure of inhibitory mechanism of Failure of inhibitory mechanism of
musculotendinous unitmusculotendinous unit Rupture tends to occur in distal 2-6 cmRupture tends to occur in distal 2-6 cm
Achilles Tendon Rupture cont.Achilles Tendon Rupture cont.
Age and genderAge and gender Previous or current tendinosis, age-related Previous or current tendinosis, age-related
changes in tendon, deconditioningchanges in tendon, deconditioning Corticosteroid injectionsCorticosteroid injections Characteristics of ruptureCharacteristics of rupture
Figure 5-29, page 175Figure 5-29, page 175 Thompson TestThompson Test
Box 5-10, page 177Box 5-10, page 177 TreatmentTreatment
Subluxating Peroneal TendonsSubluxating Peroneal Tendons
Evaluation FindingsEvaluation Findings Table 5-14, page 178Table 5-14, page 178
Forceful, sudden DF/EV or PF/INV = Forceful, sudden DF/EV or PF/INV = stretch or rupture of superior peroneal stretch or rupture of superior peroneal retinaculumretinaculum
Tendon alignment Tendon alignment Figure 5-30, page 176Figure 5-30, page 176
Subluxating Peroneal Tendons Subluxating Peroneal Tendons cont.cont.
Predisposing factorsPredisposing factors Flattened fibular grooveFlattened fibular groove Pes planusPes planus Hindfoot valgusHindfoot valgus Recurrent ankle sprainsRecurrent ankle sprains Laxity of peroneal retinaculumLaxity of peroneal retinaculum
CharacteristicsCharacteristics TreatmentTreatment
Neurovascular DeficitNeurovascular Deficit
Disruption of blood or nerve supply to or Disruption of blood or nerve supply to or from lower legfrom lower leg Acute traumaAcute trauma Overuse conditionsOveruse conditions Congenital defectsCongenital defects SurgerySurgery
Dermatomes, reflexes, pulsesDermatomes, reflexes, pulses
Anterior Compartment SyndromeAnterior Compartment Syndrome
Evaluation FindingsEvaluation Findings Table 5-15, page 179Table 5-15, page 179
Increased pressure in compartment Increased pressure in compartment threatens integrity of lower leg, foot, and threatens integrity of lower leg, foot, and toestoes Obstructs neurovascular network Obstructs neurovascular network
• Deep peroneal nerveDeep peroneal nerve• Anterior tibial arteryAnterior tibial artery
Anterior Compartment Syndrome Anterior Compartment Syndrome cont.cont.
Bony posterolateral border and dense Bony posterolateral border and dense fibrous fascial lining = poor elastic fibrous fascial lining = poor elastic propertiesproperties Cannot accommodate for expansion of Cannot accommodate for expansion of
intracompartmental tissuesintracompartmental tissues Increased pressure = lack of oxygen to local Increased pressure = lack of oxygen to local
tissuestissues• Leads to ischemia and possibly cell deathLeads to ischemia and possibly cell death
Anterior Compartment Syndrome Anterior Compartment Syndrome cont.cont.
3 classifications3 classifications Traumatic Traumatic
• blow to anterior or anterolateral portion of lower legblow to anterior or anterolateral portion of lower leg Exertional Exertional
• acute or chronic; during or after exercise (or both)acute or chronic; during or after exercise (or both) Chronic (recurrent or intermittent claudication)Chronic (recurrent or intermittent claudication)
• Occurs secondary to anatomic abnormalities Occurs secondary to anatomic abnormalities obstructing blood flow to exercising musclesobstructing blood flow to exercising muscles
• Increased thickness of fascia inhibits venous Increased thickness of fascia inhibits venous outflow outflow
• Other anatomic factors – page 178Other anatomic factors – page 178
Anterior Compartment Syndrome Anterior Compartment Syndrome cont.cont.
Associated withAssociated with Tibial fracturesTibial fractures Anticoagulant therapyAnticoagulant therapy DiabetesDiabetes Knee bracesKnee braces High-heeled shoesHigh-heeled shoes
Signs and SymptomsSigns and Symptoms 5 P’s5 P’s
• Pain, pallor, pulselessness, paresthesia, paralysisPain, pallor, pulselessness, paresthesia, paralysis
Anterior Compartment Syndrome Anterior Compartment Syndrome cont.cont.
Drop foot gaitDrop foot gait Dorsalis pedis pulse (Figure 5-31, pg 180)Dorsalis pedis pulse (Figure 5-31, pg 180) Most important clinical findingMost important clinical finding
Severe pain with passive muscle stretchingSevere pain with passive muscle stretching Medical emergencyMedical emergency
Decreased pulse, paresthesia, paralysisDecreased pulse, paresthesia, paralysis Compartmental pressureCompartmental pressure TreatmentTreatment
Deep Vein ThrombophlebitisDeep Vein Thrombophlebitis
Inflammation of veins with associated Inflammation of veins with associated blood clotsblood clots
Common in postsurgical patientsCommon in postsurgical patients May be secondary to trauma to lower May be secondary to trauma to lower
extremityextremity Pain and tightness in calf during walkingPain and tightness in calf during walking
Inspection – swelling in calfInspection – swelling in calf Palpation – warmth, tightness, painPalpation – warmth, tightness, pain
Homan’s sign Homan’s sign Box 5-11, page 181Box 5-11, page 181
On-Field Evaluation of Lower Leg On-Field Evaluation of Lower Leg and Ankle Injuriesand Ankle Injuries
GoalsGoals Rule out fractures and dislocationsRule out fractures and dislocations Determine weight-bearing statusDetermine weight-bearing status Removal methodsRemoval methods
Equipment ConsiderationsEquipment Considerations
Footwear RemovalFootwear Removal Rule out fracture/dislocation and then remove Rule out fracture/dislocation and then remove
shoeshoe Figure 5-32, page 181Figure 5-32, page 181 Apprehensive athletes – remove themselvesApprehensive athletes – remove themselves If fracture is suspected – check pulsesIf fracture is suspected – check pulses
Tape and Brace RemovalTape and Brace Removal Similar to shoe removalSimilar to shoe removal Tape is cut on opposite side of injuryTape is cut on opposite side of injury
On-Field HistoryOn-Field History Mechanism of injuryMechanism of injury
• InversionInversion• EversionEversion• RotationRotation• DorsiflexionDorsiflexion• PlantarflexionPlantarflexion
Associated sounds and sensationsAssociated sounds and sensations
On-Field InspectionOn-Field Inspection On-Field PalpationOn-Field Palpation
Bony palpationBony palpation Soft tissue palpationSoft tissue palpation
On-Field Range of Motion TestsOn-Field Range of Motion Tests Willingness to move involved limbWillingness to move involved limb Willingness to bear weightWillingness to bear weight
Initial Management of On-Field Initial Management of On-Field InjuriesInjuries
Ankle Dislocations (talocrural joint)Ankle Dislocations (talocrural joint) Excessive rotation combined with INV or EVExcessive rotation combined with INV or EV Disruption of capsule/ligaments, fractures of malleoli, Disruption of capsule/ligaments, fractures of malleoli,
long bones, taluslong bones, talus Pain, loss of function, audible soundsPain, loss of function, audible sounds Figure 5-33, page 183Figure 5-33, page 183 Confirm presence of pulsesConfirm presence of pulses
Lower Leg FracturesLower Leg Fractures Signs/symptoms (Figure 5-34, page 183)Signs/symptoms (Figure 5-34, page 183) Fibula – may be able to walkFibula – may be able to walk Bump/squeeze testsBump/squeeze tests
Management of Lower Leg Management of Lower Leg Fractures and DislocationsFractures and Dislocations
Immediately immobilizedImmediately immobilized Moldable or vacuum splintsMoldable or vacuum splints
Leave shoe on until emergency roomLeave shoe on until emergency room Figure 5-35, page 183Figure 5-35, page 183 Compound fracture Compound fracture
Control bleedingControl bleeding TreatmentTreatment
Figure 5-36, page 184Figure 5-36, page 184
Anterior Compartment SyndromeAnterior Compartment Syndrome
Avoid compressionAvoid compression Acute gross hemorrhage or absent Acute gross hemorrhage or absent
dorsalis pedis pulse – immediate refer to dorsalis pedis pulse – immediate refer to physicianphysician
Educate athletesEducate athletes