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116 Cards in this Set

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What imaging modalities are best for tendinopathies?
MRI and Ultrasound
Name 5 intrinsic factors that influence sports injury.
1. fatigue
2. gender
3. training
4. previous injury
5. BMX
Name 5 extrinsic factors that may contribute to sports injury
1. playing surface
2. footwear
3. temperature
4. playing schedule
5. other players (contact sports)
How would you decide whether to Xray an acute ankle sprain?
apply the Ottawa Ankle Rules
From what age do the Ottawa Rules apply?
>18 years old
What factors contribute to "weak ankles" after lateral ankle sprains?
1. inadequate rehabilitation
2. propriceptive loss
3. ligamentous laxity
What percentage of ankle injuries are inversion injuries?
85%
Why is inversion sprain more common that eversion sprains?
Anatomy. Deltoid ligaments (medial ankle) are stronger than lateral ligaments.
What sports activities are common mechanisms of injury for lateral ankle sprains?
Cutting, Jumping, Twisting
Which ligament is most often damaged in lateral ankle sprains?
Anterior Talofibular ligament
Which ligament is taut when the ankle is in plantarflexion?
Anterior Talofibular Ligament
Which ligament is slack when the ankle is plantarflexed?
the Calcaneo-Fibular Ligament
What other structure is commonly damaged simultaneously to the ATFL?
Anterior TibioFibular Ligament
What kind of joint is the Anterior TibioFibular?
a Syndesmosis
What is the name given to the combined ATFL and Anterior TibioFibular Ligament injury?
-
Name the 5 main ligaments of the lateral ankle, from anterior to posterior
Anterior Talofibular Ligament
Anterior TibioFibular Ligament
CalcaneoFibular Ligament
Posterior TaloFibular Ligament
Posterior TibioFibular Ligament
How would you assess proprioception after ankle sprain?
Romberg's Test
How would you assess the Anterior TaloFibular Ligament?
Anterior Drawer Test
What does the Talar Tilt Test assess?
whether the CalcaneoFibular Ligament is damaged
Why is the PRICE protocol insufficient for rehabilitation of lateral ankle sprains?
Because it is focused only on the very acute stage of the injury.
Name the 3 main causes of Peroneal Tendinopathy
1. acute ankle inversion sprain
2. secondary to Overuse
3. Soft footwear
Overuse injury of the peroneals may be caused by? (4 items).
1. Excessive Eversion
2. Excessive Pronation
3. Tight ankle plantarflexors
4. Sports that stress the peroneals
Name the 3 main sites of peroneal tendinopathy, from proximal to distal.
1. posterior to lateral malleolus
2. Peroneal Trochlea
3. Plantar Cuboid surface
As the peroneals pass laterally and anteriorly around the lateral ankle, which tendon lies above and which below the peroneal trochlea?
Brevis aBove
Longus beLow
Rest after a moderate ankle sprain should be for how many days?
3 days
Name some ways of achieving external stability to the ankle joint.
- taping
- bracing
- aircast boot
What causes loss of proprioception after an ankle injury?
mechanoreceptors are damaged
What tendon group is often damaged during an ankle inversion sprain?
Peroneals
What ankle movement will also likely be restricted if there is peroneal tendinopathy? Why?
ankle dorsiflexion

because the Achilles Tendon often has problems too
What is the commonest overuse injury causing lateral ankle sprain?
Peroneal Tendinopathy
What does MRI show if there is tendinopathy?
Increased Signal & Tendon Thickening
How does peroneal tendinopathy present in clinic?
Lateral ankle pain & swelling
Pain worse on activity
Tender course of tendons
Pain on passive inversion
Pain on active eversion in PF
Tight calves
Stiff or very pronated STJ
What passive and active joint movements will elicit pain in peroneal tendinopathy?
Passive Inversion
Active Eversion with Plantarflexion
What imaging modality would you use to assess tendinopathy?
MRI
Name two ways you could do proprioception training.
- wobble board
- heel raises
- stand on one leg (eyes closed/open)
Name 8 treatment modalities for peroneal tendinopathy
1. Rest (from activity)
2. Analgesia
3. Stretching
4. Mobilisation
5. Orthoses
6. Muscle Strengthening
7. Soft Tissue Therapy
8. Footwear review
Describe an exercise you can give to strengthen the peroneals.
Resisted eversion (in plantarflexion) using a Theraband
Why might you prescribe orthoses after peroneal tendinopathy?
To correct biomechanical abnormalities.
Name two ways of assessing for Sinus Tarsi Syndrome?
1. direct dorsal compression over Sinus Tarsi
2. STJ Eversion and Inversion
What response would you expect from direct dorsal pressure over the Sinus Tarsi, if there was injury to this structure?
Pain and/or numbness
What injury is common with sports played on hard surfaces or intermittent training?
stress fractures
What is the purpose of laser therapy for tendinopathies?
helps collagen synthesis and healing of fibres
What is the best evidence-based treatment for tendinopathy?
Eccentric exercising and Ultrasound
What is the name given to the eccentric exercise protocol for tendinopathies?
Alfredson Protocol
Describe the Alfredson Protocol
3 sets of 15 reps
eccentric heel drops
2x/day, 7days/per week for 12 weeks
– Work through non non-
disabling pain
– Progressively add
weight
What do you need to take into consideration if prescribing an orthosis for an athlete?
Their BMX will differ between normal walking and their sport
What accessory bones manifest around the lateral ankle?
Os peroneum - in P.Longus tendon
Os Vesalianum - nxt to styloid
Os Trigonum - posterior talus
What alternative exercises might you suggest for an injured sportsperson?
cardiovascular activity non WB:
- swimming
- cycling
- eliptical trainer
What is "relative rest"?
the principle of exercising the parts that still function, so as not to lose condition of non-injured areas
How would you assess if the Achilles Tendon was ruptured?
Thompson Squeeze Test
Describe how you would perform the Thompson Squeeze Test
Patient prone, ankles off bench
squeeze gastroc muscle med--lat
If foot plantarflexes=not ruptured
Typically, what does a tendon with Achilles Tendinopathy feel like on palpation?
Rigid & Thickened
What is paratenonitis?
Inflammation of the sheath around a tendon
How would you differentiate between paratenonitis and tendinopathy?
Patient prone, DF-ing ankle
Focus on lesion
If lesion sTays sTaTic=Tendinopathy
What are the 2 most common locations of Achilles Tendinopathy?
Insertional and Mid-Portion
What does the P-Q-R-S-T method mean?
Provocative or palliative
Quality and quantity
Regional or Radiating
Severity and Scale
Timing
What might the athlete recall hearing on injuring their lateral ankle in inversion?
an audible crack, pop or tear
How do acute ankle sprains present in the first 24hrs?
swollen, tender, painful
possibly no weightbearing
Immediate approach to ankle injury?
1. Assess ligament damage
2. Assess instability
3. Grade injury
4. Ottawa Ankle Protocol
Describe the grades of ligamentous injury, in terms of ROM
Grade1: normal ROM, firm endpoint
Grade 2: increased ROM, form endpoint
Grade 3: joint laxity, no end point
What is best practice for treating Grade 3 ligament sprains?
Evidence suggests 6 weeks of conservative treatment
What does the evidence tell us about conservative vs surgical approaches for ankle ligament injury?
Early mobilisation gives better outcomes, less stiffness and earlier return than surgical
What are the 2 main goals of RICE protocol?
To Reduce Swelling
To Protect the Joint
What protocol should be used to rehabilitate ankle injury?
T-E-M-P-E-R
Timely diagnosis
Edema reduction
Muscle strengthening
Proprioceptive training
Early return to activity
Rehabilitation
What are the 2 most common locations of Achilles Tendinopathy?
Insertional and Mid-Portion
What does the P-Q-R-S-T method mean?
Provocative or palliative
Quality and quantity
Regional or Radiating
Severity and Scale
Timing
What might the athlete recall hearing on injuring their lateral ankle in inversion?
an audible crack, pop or tear
How do acute ankle sprains present in the first 24hrs?
swollen, tender, painful
possibly no weightbearing
Immediate approach to ankle injury?
1. Assess ligament damage
2. Assess instability
3. Grade injury
4. Ottawa Ankle Protocol
Describe the grades of ligamentous injury, in terms of ROM
Grade1: normal ROM, firm endpoint
Grade 2: increased ROM, form endpoint
Grade 3: joint laxity, no end point
What is best practice for treating Grade 3 ligament sprains?
Evidence suggests 6 weeks of conservative treatment
What does the evidence tell us about conservative vs surgical approaches for ankle ligament injury?
Early mobilisation gives better outcomes, less stiffness and earlier return than surgical
What are the 2 main goals of RICE protocol?
To Reduce Swelling
To Protect the Joint
What protocol should be used to rehabilitate ankle injury?
T-E-M-P-E-R
Timely diagnosis
Edema reduction
Muscle strengthening
Proprioceptive training
External Stability
Return to activity
Explain how you might approach muscle strengthening in rehabilitating a lateral ankle sprain.
- Early joint mobilisation.
- Progressive active exercise
- Therabanding
- Include all planes of motion
Explain how you would carry out propriceptive training in ankle rehab.
1. Assess proprioception
2. Rockerboard or Trampoline
3. progressively harder
4. Perform functional activities
When should functional exercises be given?
once patient is painfree, full ROM, good muscle strangth and proprioception good
How long should an athlete continue to wear external support to the joint for, following serious ankle ligament injury?
6-12 months post-injury
Name the 5 aspects you should assess of ankle injury.
Pain
Instability
Functional deficit
Grade of Sprain
Associated Injuries
If no improvement in function, pain or ROM occurs after 6 weeks of rehab, what problems might you suspect?
Osteochondral body in joint
Tendon dislocation
Intraarticular fracture
Chronic ligament laxity
What ankle injury mioght be sustained if there was compressive force through the joint?
osteochondral injury
The patient reports pain on plantarflexion with inversion - what does this suggest?
Anterior TaloFibular Ligament Sprain
What imaging modality will be required for suspected osteochondral injury? Why?
CT or MRI
Osteochondral injury doesn't show up on Xray
What can you use to minimise swelling in the initial 24hrs after acute ankle injury?
Compression stocking
U-shaped Malleolar Padding
Crepe bandage
Elevate limb
What is the normal ROM at the ankle?
DF 15 degrees
PF 40 degrees
In what planes does the ankle joint move?
-
Which dermatome(s) cover the lateral ankle?
L5 lateral leg
How would you test peroneal strength?
Resisted eversion.
What is the close-packed position of the ankle?
Maximum Dorsiflexion - the talus is wider anteriorly than posteriorly
Which of the peroneal muscles lies deep to which?
Peroneus Brevis is Deepest
Which nerve innervates the lateral compartment muscles?
Superficial Peroneal Nerve
What type of joint is the ankle?
synovial hinge joint
What is the function of the lateral ankle retinaculae?
stabilise the peroneals
What venous vessel is in the lateral ankle?
The small saphenous vein runs posterior to the lateral malleolus
Name the insertions of the Peroneus Longus muscle
Base of 1st Met medial cuneiform
How would you stress the Anterior TibioFibular Ligament?
Rotate the foot, Dorsiflex the ankle
What is meant by "tendinopathy"?
A spectrum of tendon disorder ranging from inflammation of the tendon, its sheath, to tendon rupture.
What is a Jones' fracture?
Fracture of the proximal diaphysis of the 5th met.
What are the two common causes of a Jones' fracture?
1. Inversion/plantarflexion injury
2. Overuse (stress fracture)
What is the treatment for an avulsion fracture of peroneal from the styloid process?
immobilisation 2-3 weeks
relative rest & mobilisation
What mechanism of injury can cause peroneal dislocation?
Passive dorsiflexion injury.
Why do the peroneals dislocate in injury?
damage to the retinaculum
tendons slip out of their groove
Sequel to peroneal dislocation?
peroneals prone to recurrent subluxation
What is sinus tarsi syndrome?
an overuse injury secondary to excessive pronation or recurrent ankle sprain
Name 2 etiologies for sinus tarsi syndrome?
1. interosseous taolcalcaneal ligament sprain
2. compression of structures in the sinus
How will sinus tarsi syndrome present?
1. pain over sinus tarsi on direct dorsal compression
2. pain on passive inversion and eversion of STJ
What additional modality may be used to diagnose sinus tarsi syndrome?
Injection of LA into sinus tarsi
Treatment of sinus tarsi syndrome?
NSAIDs
controlling STJ motion
relative rest
What is cuboid syndrome?
subluxation/rotation of the cuboid
What forces cause cuboid subluxation, commonly?
Excessive traction from Peroneus Longus pulls lateral side upwards.
How will cuboid subluxation present?
- Dorsal depression over cuboid
- lateral foot pain radiating plantar-medially
- push-off feels weak
Diagnosing cuboid subluxation?
- visible depression over cuboid
- no movement on direct pressure
Treatment for cuboid syndrome?
-Manipulation
-Cuboid Pad
-Ice and Taping
List the 5 main Ddx for lateral ankle sprain
1. Peroneal dislocation
2. Fractures (avulsion, stress or Jones)
3. Sinus Tarsi
4. Syndesmosis
5. Cuboid syndrome
Name 3 ways you would assess for a syndesmosis sprain?
1. tenderness over ligament
2. pain on DF + Inversion
3. wide ankle mortice on X-ray
What is the name for the injury involving sprain of the Anterior TibioFibular Ligament, the interosseous ligament and proximal fibular fracture?
a Maisonneuve fracture