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Chapter 19: The Ankle and Lower Leg

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Ligament arrangement limits inversion and eversion at the subtalar joint ... Normal ankle function is dependent on action of the rearfoot and subtalar joint ... – PowerPoint PPT presentation

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Title: Chapter 19: The Ankle and Lower Leg


1
Chapter 19 The Ankle and Lower Leg
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Functional Anatomy
  • Ankle is a stable hinge joint
  • Medial and lateral displacement is prevented by
    the malleoli
  • Ligament arrangement limits inversion and
    eversion at the subtalar joint
  • Square shape of talus adds to stability of the
    ankle
  • Most stable during dorsiflexion, least stable in
    plantar flexion

10
  • Degrees of motion for the ankle range from 10
    degrees of dorsiflexion to 50 degrees of plantar
    flexion
  • Normal gait requires 10 degrees of dorsiflexion
    and 20 degrees of plantar flexion with the knee
    fully extended
  • Normal ankle function is dependent on action of
    the rearfoot and subtalar joint

11
Preventing Injury in the Lower Leg and Ankle
  • Achilles Tendon Stretching
  • A tight heel cord may limit dorsiflexion and may
    predispose athlete to ankle injury
  • Should routinely stretch before and after
    practice
  • Stretching should be performed with knee extended
    and flexed 15-30 degrees
  • Strength Training
  • Static and dynamic joint stability is critical in
    preventing injury
  • While maintaining normal ROM, muscles and tendons
    surrounding joint must be kept strong

12
  • Neuromuscular Control Training
  • Can be enhanced by training in controlled
    activities on uneven surfaces or a balance board
  • Footwear
  • Can be an important factor in reducing injury
  • Shoes should not be used in activities they were
    not made for
  • Preventive Taping and Orthoses
  • Tape can provide some prophylactic protection
  • However, improperly applied tape can disrupt
    normal biomechanical function and cause injury
  • Lace-up braces have even been found to be
    superior to taping relative to prevention

13
Assessing the Lower Leg and Ankle
  • History
  • Past history
  • Mechanism of injury
  • When does it hurt?
  • Type of, quality of, duration of pain?
  • Sounds or feelings?
  • How long were you disabled?
  • Swelling?
  • Previous treatments?

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  • Observations
  • Postural deviations?
  • Genu valgum or varum?
  • Is there difficulty with walking?
  • Deformities, asymmetries or swelling?
  • Color and texture of skin, heat, redness?
  • Patient in obvious pain?
  • Is range of motion normal?

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Palpation Bones and Soft Tissue
  • Fibular head and shaft
  • Lateral malleolus
  • Tibial plateau
  • Tibial shaft
  • Medial malleolus
  • Dome of talus
  • Calcaneus
  • Peroneus longus
  • Peroneus brevis
  • Peroneus tertius
  • Flexor digitorum longus
  • Flexor hallucis
  • Posterior tibialis

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Palpation Soft Tissue (continued)
  • Anterior tibialis
  • Extensor hallucis longus
  • Extensor digitorum longus
  • Gastrocnemius
  • Soleus
  • Achilles tendon
  • Anterior/posterior talofibular ligament
  • Calcaneofibular ligament
  • Deltoid ligament
  • Anterior tibiofibular ligament
  • Posterior tibiofibular ligament

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  • Special Test - Lower Leg
  • Lower Leg Alignment Tests
  • Malalignment can reveal causes of abnormal
    stresses applied to foot, ankle, lower leg, knees
    and hips
  • Anteriorly, a straight line can be drawn from
    ASIS, through patella and between 1st and 2nd
    toes
  • Laterally, a straight line can go from greater
    trochanter through center of patella and just
    behind the lateral malleolus
  • Posteriorly, a line can be drawn through the
    center of the lower leg, midline to the Achilles
    and calcaneus
  • Internal or external tibial torsion is also a
    common malalignment

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  • Percussion and compression tests
  • Used when fracture is suspected
  • Percussion test is a blow to the tibia, fibula or
    heel to create vibratory force that resonates
    w/in fracture causing pain
  • Compression test involves compression of tibia
    and fibula either above or below site of concern
  • Thompson test
  • Squeeze calf muscle, while foot is extended off
    table to test the integrity of the Achilles
    tendon
  • Positive tests results in no movement in the foot
  • Homans test
  • Test for deep vein thrombophlebitis
  • With knee extended and foot off table, ankle is
    moved into dorsiflexion
  • Pain in calf is a positive sign and should be
    referred

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Compression Test
Percussion Test
Homans Test
Thompson Test
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  • Ankle Stability Tests
  • Anterior drawer test
  • Used to determine damage to anterior talofibular
    ligament primarily and other lateral ligament
    secondarily
  • A positive test occurs when foot slides forward
    and/or makes a clunking sound as it reaches the
    end point
  • Talar tilt test
  • Performed to determine extent of inversion or
    eversion injuries
  • With foot at 90 degrees calcaneus is inverted and
    excessive motion indicates injury to
    calcaneofibular ligament and possibly the
    anterior and posterior talofibular ligaments
  • If the calcaneus is everted, the deltoid ligament
    is tested

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Anterior Drawer Test
Talar Tilt Test
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  • Kleigers test
  • Used primarily to determine extent of damage to
    the deltoid ligament and may be used to evaluate
    distal ankle syndesmosis, anterior/posterior
    tibiofibular ligaments and the interosseus
    membrane
  • With lower leg stabilized, foot is rotated
    laterally to stress the deltoid
  • Medial Subtalar Glide Test
  • Performed to determine presence of excessive
    medial translation of the calcaneus on the talus
  • Talus is stabilized in subtalar neutral, while
    other hand glides the calcaneus, medially
  • A positive test presents with excessive movement,
    indicating injury to the lateral ligaments

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Kleigers Test
Medial Subtalar Glide Test
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  • Functional Tests
  • While weight bearing the following should be
    performed
  • Walk on toes (plantar flexion)
  • Walk on heels (dorsiflexion)
  • Walk on lateral borders of feet (inversion)
  • Walk on medial borders of feet (eversion)
  • Hops on injured ankle
  • Passive, active and resistive movements should be
    manually applied to determine joint integrity and
    muscle function
  • If any of these are painful they should be avoided

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Specific Injuries
  • Ankle Injuries Sprains
  • Single most common injury in athletics caused by
    sudden inversion or eversion moments
  • Inversion Sprains
  • Most common and result in injury to the lateral
    ligaments
  • Anterior talofibular ligament is injured with
    inversion, plantar flexion and internal rotation
  • Occasionally the force is great enough for an
    avulsion fracture to occur w/ the lateral
    malleolus

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  • Severity of sprains is graded (1-3)
  • With inversion sprains the foot is forcefully
    inverted or occurs when the foot comes into
    contact w/ uneven surfaces

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  • Grade 1 Inversion Ankle Sprain
  • Etiology
  • Occurs with inversion plantar flexion and
    adduction with stretching of the anterior
    talofibular ligament
  • Signs and Symptoms
  • Mild pain and disability weight bearing is
    minimally impaired point tenderness over
    ligaments and no laxity
  • Management
  • RICE for 1-2 days limited weight bearing
    initially and then aggressive rehab
  • Tape may provide some additional support
  • Return to activity in 7-10 days

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  • Grade 2 Inversion Ankle Sprain
  • Etiology
  • Moderate inversion force causing great deal of
    disability with many days of lost time
  • Signs and Symptoms
  • Feel or hear pop or snap moderate pain w/
    difficulty bearing weight tenderness and edema
  • Positive talar tilt and anterior drawer tests
  • Possible tearing of the anterior talofibular and
    calcaneofibular ligaments
  • Management
  • RICE for at least first 72 hours X-ray exam to
    rule out fx crutches 5-10 days, progressing to
    weight bearing

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  • Management (continued)
  • Will require protective immobilization but begin
    ROM exercises early to aid in maintenance of
    motion and proprioception
  • Taping will provide support during early stages
    of walking and running
  • Long term disability will include chronic
    instability with injury recurrence potentially
    leading to joint degeneration
  • Must continue to engage in rehab to prevent
    against re-injury

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  • Grade 3 Inversion Ankle Sprain
  • Etiology
  • Relatively uncommon but is extremely disabling
  • Caused by significant force (inversion) resulting
    in spontaneous subluxation and reduction
  • Causes damage to the anterior/posterior
    talofibular and calcaneofibular ligaments as well
    as the capsule
  • Signs and Symptoms
  • Severe pain, swelling, hemarthrosis,
    discoloration
  • Unable to bear weight
  • Positive talar tilt and anterior drawer

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  • Management
  • RICE, X-ray (physician may apply dorsiflexion
    splint for 3-6 weeks)
  • Crutches are provided after cast removal
  • Isometrics in cast ROM, PRE and balance exercise
    once out
  • Surgery may be warranted to stabilize ankle due
    to increased laxity and instability

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Eversion Ankle Sprains -(Represent 5-10 of all
ankle sprains)
  • Etiology
  • Bony protection and ligament strength decreases
    likelihood of injury
  • Eversion force resulting to damage of deltoid and
    possibly fx of the fibula
  • Deltoid can also be impinged and contused with
    inversion sprains

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  • Etiology (continued)
  • Due to severity of injury, it may take longer to
    heal
  • Foot that is pronated, hypermobile or has a
    depressed medial longitudinal arch is more
    predisposed to eversion sprains
  • Signs and Symptoms
  • Pain may be severe unable to bear weight and
    pain with abduction and adduction but not direct
    pressure on bottom of foot
  • Management
  • RICE X-ray to rule out fx no weight bearing
    initially posterior splint tape NSAIDs
  • Follows the same course of treatment as inversion
    sprains
  • Grade 2 or higher will present with considerable
    instability and may cause weakness in medial
    longitudinal arch resulting in excessive
    pronation or fallen arch

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  • Syndesmotic Sprain
  • Etiology
  • Injury to the distal tibiofemoral joint
    (anterior/posterior tibiofibular ligament)
  • Torn w/ increased external rotation or
    dorsiflexion
  • Injured in conjunction w/ medial and lateral
    ligaments
  • Signs and Symptoms
  • Severe pain, loss of function passive external
    rotation and dorsiflexion cause pain
  • Pain is usually anterolaterally located
  • Management
  • Difficult to treat and may requires months of
    treatment
  • Same course of treatment as other sprains,
    however, immobilization and total rehab may be
    longer

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  • Ankle Fractures/Dislocations
  • Etiology
  • Number of mechanisms
  • Signs and Symptoms
  • Swelling and pain may be extreme with possible
    deformity
  • Management
  • RICE to control hemorrhaging and swelling
  • Once swelling is reduced, a walking cast or brace
    may be applied, w/ immobilization lasting 6-8
    weeks

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  • Osteochondritis Dissecans
  • Etiology
  • Occur in superior medial articular surface of the
    talar dome
  • One or several fragments of articular cartilage,
    w/ underlying subchondral bone partially or
    completely detached and moving within the joint
    space
  • Mechanism may be single trauma or repeated
    traumas
  • Signs and Symptoms
  • May be a complaint of pain and effusion with
    signs of atrophy
  • May also be catching, locking, or giving way

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  • Osteochondritis Dissecans
  • Management
  • Diagnosis through X-ray or MRI
  • Incomplete and non-displaced injuries can be
    immobilized with early motion and delayed weight
    bearing
  • If fragments are displaced, surgery is necessary
  • Surgery will minimize risk of nonunion

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  • Acute Achilles Strain
  • Etiology
  • Common in sports and often occurs with sprains or
    excessive dorsiflexion
  • Sign and Symptoms
  • Pain may be mild to severe
  • Most severe injury is partial or complete
    avulsion or rupturing of the Achilles
  • Management
  • Pressure and RICE should be applied
  • After hemorrhaging has subsided an elastic wrap
    should continue to be applied
  • Conservative treatment should be used as Achilles
    problems generally become chronic
  • A heel lift should be used and stretching and
    strengthening should begin soon

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  • Achilles Tendinitis
  • Etiology
  • Inflammatory condition involving tendon, sheath
    or paratenon
  • Tendon is overloaded due to extensive stress
  • Presents with gradual onset and worsens with
    continued use
  • Decreased flexibility exacerbates condition
  • Signs and Symptoms
  • Generalized pain and stiffness, localized
    proximal to calcaneal insertion, warmth and
    painful with palpation, as well as thickened
  • May limit strength
  • May progress to morning stiffness

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  • Crepitus with active plantar flexion and passive
    dorsiflexion
  • Chronic inflammation may lead to thickening
  • Management
  • Resistant to quick resolution due to slow healing
    nature of tendon
  • Must reduce stress on tendon, address structural
    faults (orthotics, mechanics, flexibility)
  • Use antiinflammatory modalities and medications
  • Cross friction massage may be helpful in breaking
    down adhesions
  • Strengthening must progress slowly in order to
    not aggravate the tendon

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  • Achilles Tendon Rupture
  • Etiology
  • Occurs w/ sudden stop and go forceful plantar
    flexion w/ knee moving into full extension
  • Commonly seen in athletes gt 30 years old
  • Generally has history of chronic inflammation
  • Signs and Symptoms
  • Sudden snap (kick in the leg) w/ immediate pain
    which rapidly subsides
  • Point tenderness, swelling, discoloration
    decreased ROM
  • Obvious indentation and positive Thompson test
  • Occurs 2-6 cm proximal the calcaneal insertion

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  • Achilles Tendon Rupture (continued)
  • Management
  • Usual management involves surgical repair for
    serious injuries (return of 75-90 of function)
  • Non-operative treatment consists of RICE,
    NSAIDs, analgesics, and a non-weight bearing
    cast for 6 weeks, followed up by a walking cast
    for 2 weeks (75-80 return to normal function)
  • Rehabilitation last about 6 months and consists
    of ROM, PRE and wearing a 2cm heel lift in both
    shoes

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  • Peroneal Tendon Subluxation/Dislocation
  • Etiology
  • Occurs in sports with dynamic forces being
    applied to the ankle
  • May also be caused by dramatic blow to posterior
    lateral malleolus, or moderate/severe inversion
    ankle sprain resulting in tearing of peroneal
    retinaculum
  • Signs and Symptoms
  • Complain of snapping in and out of groove with
    activity
  • Eversion against manual resistance replicates
    subluxation
  • Recurrent pain, snapping and instability
  • Present with ecchymosis, edema, tenderness, and
    crepitus over the tendon

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  • Peroneal Subluxation (continued)
  • Management
  • Conservative approach should be used first,
    including compression with felt horseshoe
  • Reinforce compression pad with rigid plastic or
    plaster until acute signs have subsided
  • RICE, NSAIDs and analgesics
  • Conservative treatment time 5-6 weeks followed by
    gradual rehab program
  • Surgery if conservative plan fails

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  • Anterior Tibialis Tendinitis
  • Etiology
  • Commonly occurs after extensive down hill running
  • Signs and Symptoms
  • Point tenderness over anterior tibialis tendon
  • Management
  • Rest or at least decrease running time and
    distance, avoid hills
  • In more serious cases, ice stretch before and
    after running to reduce symptoms
  • Daily strengthening should be conducted
  • Oral antiinflammatory medication may be required

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  • Posterior Tibial Tendinitis
  • Etiology
  • Common overuse condition in runners with
    hypermobility or over pronation
  • Repetitive microtrauma
  • Signs and Symptoms
  • Pain and swelling in area of medial malleolus
  • Edema, point tenderness and increased pain during
    resistive inversion and plantar flexion
  • Management
  • Initially, RICE, NSAIDs and analgesics
  • Non-weight bearing cast w/ foot in inversion may
    be used
  • Correct problem of over pronation with taping or
    orthotic

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  • Peroneal Tendinitis
  • Etiology
  • Not common, but can be found with athletes that
    have pes cavus due to excessive supination
    placing stress on peroneal tendon
  • Signs and Symptoms
  • Pain behind lateral malleolus during push-off or
    rising on ball of foot
  • Pain along distolateral aspect of calcaneus and
    beneath the cuboid
  • Management
  • RICE, NSAIDs, elastic taping, appropriate
    warm-up and flexibility exercises
  • LowDye taping or orthotics to help support foot

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  • Shin Contusion
  • Etiology
  • Direct blow to lower leg (impacting periosteum
    anteriorly)
  • Signs and Symptoms
  • Intense pain, rapidly forming hematoma w/ jelly
    like consistency
  • Management
  • RICE, NSAIDs and analgesics as needed
  • Maintaining compression for hematoma (which may
    need to aspirated)
  • Fit with doughnut pad and orthoplast shell for
    protection
  • If not managed appropriately may develop into
    osteomyelitis (deterioration of bone)

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  • Muscle Contusions
  • Etiology
  • Contusion of leg, particularly in the region of
    the gastrocnemius
  • Signs and Symptoms
  • Bruise may develop, pain, weakness and partial
    loss of limb function
  • Palpation will reveal hard, rigid, inflexible
    area due to internal hemorrhaging and muscle
    guarding
  • Management
  • Stretch to prevent spasm apply cold compression
    and ice
  • If superficial therapy and massage do not return
    athlete to normal in 2-3 days, ultrasound would
    be indicated
  • Wrap or tape will help to stabilize the area

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  • Leg Cramps and Spasms
  • (sudden, violent, involuntary contraction, either
    clonic (intermittent) or tonic (sustained)
  • Etiology
  • Difficult to determine fatigue, loss of fluids,
    electrolyte imbalance, inadequate reciprocal
    muscle coordination
  • Signs and Symptoms
  • Cramping with pain and contraction of calf muscle
  • Management
  • Try to help athlete relax to relieve cramp
  • Firm grasp of cramping muscle with gentle
    stretching will relieve acute spasm
  • Ice will also aid in reducing spasm
  • If recurrent may be fatigue or water/electrolyte
    imbalance

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  • Gastrocnemius Strain
  • Etiology
  • Susceptible to strain near musculotendinous
    attachment
  • Caused by quick start or stop, jumping
  • Signs and Symptoms
  • Depending on grade, variable amount of swelling,
    pain, muscle disability
  • May feel like being hit in leg with a stick
  • Edema, point tenderness and functional loss of
    strength
  • Management
  • RICE, NSAIDs and analgesics as needed
  • Grade 1 should apply gentle stretch after cooling
  • Weight bearing as tolerated heel wedge to reduce
    calf stretching while walking
  • Gradual rehab program should be instituted

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  • Acute Leg Fractures
  • Etiology
  • Fibula has highest incidence of fracture,
    occurring primarily in the middle third
  • Tibial fractures occur predominantly in the lower
    third
  • Result of direct blow or indirect trauma
  • Signs and Symptoms
  • Pain, swelling, soft tissue insult
  • Leg will appear hard and swollen (Volkmans
    contracture)
  • Management
  • X-ray, reduction, casting up to 6 weeks depending
    on the extent of injury

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  • Medial Tibial Stress Syndrome (Shin Splints)
  • Etiology
  • Pain in anterior portion of shin
  • Stress fractures, muscle strains, chronic
    anterior compartment syndrome
  • Accounts for 10-15 of all running injuries, 60
    of leg pain in athletes
  • Caused by repetitive microtrauma
  • Weak muscles, improper footwear, training errors,
    varus foot, tight heel cord, hypermobile or
    pronated feet and even forefoot supination can
    contribute to MTSS
  • May also involve, stress fractures or exertional
    compartment syndrome

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  • Shin Splints (continued)
  • Signs and Symptoms
  • Four grades of pain
  • Pain after activity
  • Pain before and after activity and not affecting
    performance
  • Pain before, during and after activity, affecting
    performance
  • Pain so severe, performance is impossible
  • Management
  • Physician referral for X-rays and bone scan
  • Activity modification
  • Correction of abnormal biomechanics
  • Ice massage to reduce pain and inflammation
  • Flexibility program for gastroc-soleus complex
  • Arch taping and or orthotics

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  • Compartment Syndrome
  • Etiology
  • Rare acute traumatic syndrome due to direct blow
    or excessive exercise
  • Signs and Symptoms
  • Excessive swelling compresses muscles, blood
    supply and nerves
  • Increase in fluid accumulation could lead to
    permanent disability
  • Chronic cases appear as gradual build-up that
    dissipates following activity generally
    bilateral and becomes predictable can remain
    elevated producing ischemia and pain or ache w/
    rare neurological increased pressure involvement
  • Weakness with foot and toe extension and
    occasionally numbness in dorsal region of foot

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  • Compartment Syndrome (continued)
  • Management
  • If severe acute or chronic case, may present as
    medical emergency that requires surgery to reduce
    pressure or release fascia
  • RICE, NSAIDs and analgesics as needed
  • Surgical release is generally used in recurrent
    conditions
  • Return to activity after surgery - light
    activity- 10 days later

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  • Stress Fracture of Tibia or Fibula
  • Etiology
  • Common overuse condition, particularly in those
    with structural and biomechanical insufficiencies
  • Runners tends to develop in lower third of leg,
    dancers middle third
  • Often occur in unconditioned, non-experienced
    individuals
  • Often training errors are involved
  • Component of female athlete triad
  • Signs and Symptoms
  • Pain more intense after exercise than before
  • Point tenderness difficult to discern bone and
    soft tissue pain
  • Bone scan results (stress fracture vs.
    periostitis)

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  • Management
  • Discontinue stress inducing activity 14 days
  • Use crutch for walking
  • Weight bearing may return when pain subsides
  • Cycling before running
  • After pain free for 2 weeks athlete can gradually
    return to running
  • Biomechanics must be addressed

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Rehabilitation Techniques
  • General Body Conditioning
  • Must be maintained with non-weight bearing
    activities
  • Weight Bearing
  • Non-weight bearing vs. partial weight bearing
  • Protection and faster healing
  • Partial weight bearing helps to limit muscle
    atrophy, proprioceptive loss, circulatory stasis
    and tendinitis
  • Protected motion facilitates collagen alignment
    and stronger healing

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  • Joint Mobilizations
  • Movement of an injured joint can be improved with
    manual mobilization techniques
  • Flexibility
  • During early stages inversion and eversion should
    be limited
  • Plantar flexion and dorsiflexion should be
    encouraged
  • With decreased discomfort inversion and eversion
    exercises should be initiated
  • BAPS board progression

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  • Strengthening
  • Isometrics (4 directions) early during rehab
    phase
  • With increased healing, aggressive nature of
    strengthening should increase (isotonic exercises
  • Pain should serve as the guideline for
    progression
  • Tubing exercises allows for concentric and
    eccentric exercises
  • PNF allows for isolation of specific motions
  • Proprioception Neuromuscular Control
  • Deficits can predispose individuals to injury
  • Athletes should engage in proprioception
    progression including double and single leg
    stances, eye open and closed, single leg kicks
    and alternating apparatuses and surfaces

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  • Taping and Bracing
  • Ideal to have athlete return w/out taping and
    bracing
  • Common practice to use tape and brace initially
    to enhance stabilization
  • Must be sure it does not interfere with overall
    motor performance
  • Functional Progressions
  • Severe injuries require more detailed plan
  • Typical progression initiated w/ partial weight
    bearing until full weight bearing occurs w/out a
    limp
  • Running can begin when ambulation is pain free
    (transition from pool - even surface - changes of
    speed and direction)

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  • Return to Activity
  • Must have complete range of motion and at least
    80-90 of pre-injury strength before return to
    sport
  • If full practice is tolerated w/out insult,
    athlete can return to competition
  • Must involve gradual progression of functional
    activities, slowly increasing stress on injured
    structure
  • Specific sports dictate specific drills
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