4 Lower Extremity 06-07

8/3/2019 4 Lower Extremity 06-07

1/40

CORE OMM Curriculumfor Students, Interns, & Residents 2006

Mini CaseMini Case

A basketball playerA basketball playerwas getting in positionwas getting in position

for a rebound when hefor a rebound when he

stepped on anotherstepped on anotherplayers foot and rolledplayers foot and rolled

his ankle. Xhis ankle. X--rays did notrays did not

reveal a fracture, but thereveal a fracture, but the

player left the game onplayer left the game on

crutches.crutches.

http://images.google.com/imgres?imgurl=http://www.kvue

.com/sharedcontent



2/40


Approaching theProblem

Differential? (break, sprain, etc.)

Tissue changes? (swelling, warmth,

ecchymosis)

Pain can patient bear weight?

ROM decreased?

Neuro deficits?

Treatment?

Dont just look at the ankle think how it affects

the rest of the patients body also


3/40


Anatomy-Lateral Ligaments

OUCOMCOREOMM curriculum session 7


4/40


Anatomy-Medial Ligaments



5/40


Anatomy of Foot/Ankle

Talus is wider anteriorly

Medial malleolus only

comes down over 1/3 of the

talus and is more anterior

Lateral malleolus covers

entire talus

Des Moines University OMM II handouts, August 12, 2002 May

15, 2003 OUCOM Session 7 LowerExtremity lecture


6/40


Anatomy

26 bones of the foot Plus 2 sesamoid bones under great toe for weight bearing and

balance

33 jointsMedial longitudinal arch

Calcaneous, talus, navicular, first 3 cuneforms, first 3metatarsals

Strengthened by calcaneonavicular (Spring) ligament

Lateral longitudinal arch

C

alcaneous, cuboid, 4th

and 5th

metatarsals Weight bearing

Transverse arches Weight bearing and springing off with foot


7/40


Biomechanics

In dorsiflexion foot everts, toeing out

Most stable position closed packed position

In plantarflexion foot inverts, toeing in

Ligaments less taut

Joint more vulnerable to injury


8/40


Biomechanics

Talo-crural joint Where distal tibia/fibula meet the talus

Flexion/extension

Subtalar joint Where calcaneous meets talus

Inversion/eversion

Transverse tarsal joints Talonavicular and calcaneocuboid joints

Adduction/abduction


9/40


Biomechanics

Pronation

Abduction Eversion

Dorsiflexion

Supination

Adduction Inversion

Plantarflexion


10/40


Cause of Ankle Sprain

85% are due to inversion

Deltoid ligament is stronger than the lateral ligaments

Anterior tibiotalar, tibiocalcaneal, tibionavicular,

and posterior tibiotalar ligaments

Lateral malleolus is longer than medial malleolus

Axis of talo-crural joint

In plantar flexion, ankle naturally inverts

In dorsiflexion, ankle is very stable


11/40


Pathoanatomy andMechanisms of Injury

The most common mechanism of injury is a combination of

plantar flexion and inversion.

The lateral stabilizing ligaments, which include the anteriortalofibular, calcaneofibular and posterior talofibular ligaments.

The anterior talofibular ligament is the most easily injured.

The posterior talofibular ligament is the strongest of the lateralcomplex and is rarely injured in an inversion sprain.


12/40


Mechanism of injury highankle sprain


13/40


Cause



14/40


Grading

Grade I: anterior talofibular ligament (ATF)

Grade II: ATF plus calcaneofibular ligament (CF)

Grade III: ATF plus CF plus posterior talofibularligament


15/40


Ligaments used inGrading

Des Moines University OMM II handouts, August 12, 2002 May 15, 2003

OUCOM Session 7 LowerExtremity lecture


16/40


Diagnosis

History of trauma

Swelling/discoloration

Pain/tenderness

Eversion restriction

Anterior drawer test for

ankle

X-ray

www.uwec.edu/kin/majors/AT/aidil/images/Ankle.JPG


17/40


DX: The anterior drawer testand the inversion stress test

The anterior drawer test can be

used to assess the integrity ofthe anterior talofibular ligament.

The inversion stress test can beused to assess the integrity ofthe calcaneofibular ligament.


18/40


Diagnosis

The entire length of the tibia and fibula should be palpated to

detect fracture of the proximal fibula (Maisonneuve fracture),

which may be associated with syndesmosis injury.

Tenderness along the base of the fifth metatarsal may indicate

an avulsion of the peroneal brevis tendon.

Effusion along the talocrural joint line should raise suspicion of

an osteochondral talar dome lesion.


19/40


Special Tests

A "squeeze test," performed by compressing the fibula and tibia

at the midcalf, positive if pain is elicited distally.

An "external rotation test" to identify a syndesmosis sprain. With

the patient's knee resting over the edge of the table. The

physician stabilizes the leg proximal to the ankle joint while

grasping the plantar aspect of the foot and rotating the foot

externally relative to the tibia. Pain the test is positive


20/40


Ottawa Ankle Rules

Radiographs should be obtained to rule out fracture when a

patient presents (within 10 days of injury) with bone tenderness

in the posterior half of the lower 6 cm (2.5 in) of the fibula or tibia

or an inability to bear weight immediately after the injury.

Bone tenderness over the navicular bone or base of the fifth

metatarsal is an indication for radiographs.

Anteroposterior, lateral and mortise radiographs should be

obtained after the initial physical examination. The mortiseprojection is an anteroposterior view obtained with the leg

internally rotated 15 to 20 degrees.


21/40


Functional Rehabilitation

Prolonged immobilization of ankle sprains is a commontreatment error. Functional stress stimulates the incorporationof stronger replacement collagen.

The four components of rehabilitation are:

1. Range-of-motion rehabilitation

2. Progressive muscle-strengthening exercises

3. Proprioceptive training

4. Activity-specific training


22/40


Range of Motion

Achilles tendon stretch, nonweight-bearing. Use a towel to pull

foot toward face. Pain-free stretch for 15 to 30 seconds; perform

five repetitions; repeat three to five times a day. Maintain

extremity in a nongravity position with compression.

Achilles tendon stretch, weight-bearing. Stand with heel on floor

and bend at knees. Pain-free stretch for 15 to 30 seconds;

perform five repetitions; repeat three to five times a day.

Alphabet exercises, Move ankle in multiple planes of motion by

drawing letters of alphabet (lower case and upper case).

Repeat four to five times a day.Exercises can be performed in

conjunction with cold therapy.


23/40


Muscle Strengthening

Isometric exercises, Resistance can be provided by immovable

object (wall or floor) or contralateral foot. For each exercise,

hold 5 seconds; do 10 repetitions; repeat three times a day.

Strengthening exercises should only be done in positions that

do not cause pain.

Plantar flexion, Push foot downward (away from head).

Dorsiflexion, Pull foot upward (toward head).

Inversion, Push foot inward (toward midline of body).

Eversion, Push foot outward (away from midline of body).

For each exercise, hold 1 second for concentric component andperform eccentric component over 4 seconds; do three sets of

10 repetitions; repeat two times a day.


24/40


Muscle-StrengtheningExercises

FIGURE 8.Achilles tendon stretching using a towel.

FIGURE 9.Use of elastic tubing in strengthening exercises for eversion.

AAFP website article; Management of Ankle Sprains January 1, 2001


25/40


Muscle Strengthening

Toe curls and marble pickups, Place foot on a towel;then curl toes, moving the towel toward body.Use toes to pick up marbles or other small object.Two sets of 10 repetitions; repeat two times aday.Toe curls can be done throughout the day, atwork or at home.

Toe raises, heel walks and toe walks,

Lift body by rising up on toes. Walk forward and

backward on toes and heels.Three sets of 10repetitions; repeat two times a day; progress walkingas tolerated. Strengthening can occur from using thebody as resistance in weight- bearing position.


26/40


Muscle-StrengtheningExercises

FIGURE 10.Single-leg toe raises done on a step.

FIGURE 11.Single-leg wobble board exercise to increase

proprioception.

AAFP website article; Management of Ankle Sprains January 1, 2001


27/40


Range of Motion

Range of motion must be regained before functional

rehabilitation is initiated.

Regardless of weight-bearing capacity, Achilles tendon

stretching should be instituted within 48 to 72 hours after theankle injury because of the tendency of tissues to contract

following trauma.

Once range of motion is attained, and swelling and pain are

controlled, the patient is ready to progress to the strengtheningphase of rehabilitation.


28/40


Rehabilitation/Strengthening


29/40


Training for Return toActivity

When walking a specified distance is no longer limited by pain,

the patient may progress to a regimen of 50 percent walking and

50 percent jogging.

When this can be done without pain, jogging eventually

progresses to forward, backward and pattern running. Circles

and figure-eights are commonly employed for pattern running.

Although these routines are time-consuming, they represent thefinal phase and are essential for the recovery of ankle stability.


30/40


Treatment

X-ray

Reset the talus in the mortise of ankle

Milk the peroneal muscles

Correct ipsilateral posterior fibular head

Correct ipsilateral posterior 3rd rib

RICE (rest, ice, compression, elevation) Rehabilitate peroneal and tibialis anterior muscles


31/40


Reset the Talus in theMortise

Apply traction with dorsiflexion and eversion

Quick tug to reset the talus in the mortise




32/40


Milk the Peroneal Muscles

Start distally andwork your way

proximally




33/40


Correct ipsilateral posteriorfibular head - Passive Motion

Patient supine, knee flexed

Sit on foot

Stabilize knee with hand

Pull fibular head anterolaterally andthen push posteromedially repeatedly

Des Moines University OMM II handouts, August 12, 2002 May15, 2003 OUCOM Session 7 Lower Extremity lecture


34/40


Correct ipsilateral posteriorfibular head Muscle Energy

Remember PIP AID

For a Posterior fibular head, Invert

and Plantarflex

For an Anterior fibular head,

Invert and Dorsiflex




35/40


Correct ipsilateral posteriorfibular head - HVLA

Patient supine, knee flexed

Physicians hand in

popliteal fossa, 1st MCPjoint behind fibular head

Flex knee, externally rotate

leg at knee

Thrust patients ankletoward buttocks




36/40


Correct IpsilateralPosterior3rdRib

Full Nelson

Physicians hands behind patients head, patients hands on top of physicians Rotate head toward posterior rib Sidebend toward rib Rotate away from rib Thrust at end of exhalation

Strain/Counterstrain Patient seated Physician foot on table same side as rib Patients arm on physicians leg Flex patients head Patient leans back, other arm off table behind Sidebend and rotate patient away

Still

Patient seated, physician behind patient Extend, abduct arm until release, exaggerate Add compressive force through humerus toward rib head




37/40


Treatment - Still Technique

1. Put ankle in position of ease

2. Add activating force of gentle

compression or distraction3. Move slowly toward barrier

4. Return to neutral

OK for acute sprains


38/40


Lab Exercises

Anterior drawer test for ankle

Reset the talus in the mortise

Milk the peroneal muscles

Posterior fibular head correction

Muscle energy

Passive motion

HVLA

Still technique


39/40


What would A.T. Still do?

American Osteopathic Association copyright 2003-2006


40/40


References



http://www.uwec.edu/kin/majors/AT/aidil/images/Ankle.JPG

Management of

Ankle SprainsMICHAEL W. WOLFE, M.D.,

Lewis-Gale Clinic, Salem, Virginia

TIML. UHL, PH.D., A.T.-C., P.T., and CARLG. MATTACOLA,

PH.D, A.T.-C.

University of Kentucky College of Allied Health Professions,

Lexington, Kentucky

LELANDC. MCCLUSKEY, M.D.,Hughston Clinic, Columbus, Georgia

Date post:	06-Apr-2018
Category:	Documents
Upload:	mandy8403
View:	218 times
Download:	0 times

4 Lower Extremity 06-07

Documents