Metatarsal Stress Fracture: A Unique Presentation

02/23/2020 1 22ND ANNUAL ORTHOPAEDIC AND SPORTS MEDICINE CONFERENCE FOOT AND ANKLE MANAGEMENT FOR THE INJURED DANCER Presented by: Jonathan Reynolds, PT, PhD 02/23/2020 Diagnostic Excellence Detailed history Thorough examination Radiology dependence Three major concerns: Posterior pain Plantar foot pain

Recruitment/poor co-ordination Practicum Examination Treatment 2 02/23/2020 SCENARIO 1: POSTERIOR ANKLE PAIN 3 02/23/2020 Posterior Ankle Pain Achilles tendinitis Posterior impingement Talocrural joint Os Trigonum

Steidas Process FHL Tendinitis Talar stress fracture/OCD Talocrural malalignment Anterior translation Posterior translation 4 02/23/2020 5 Achilles Tendinitis Pain at: Anterior aspect (soleus) of Achilles tendon Pathomechanics Overuse (jumping, releve, running) Evaluation

Provocative tests: Heel raise Jump Soleus stretch MMT: Up on toes PROM: ankle DF Palpation: Tenderness at soleus aspect of AT Check teno-periosteal junction at calcaneus Differentiators: 1. Surface anatomy 2. Localization of pain 3. Range of ankle motion when symptoms are felt 02/23/2020 6

Posterior Impingement Pain at: Posterior TCJ Pathomechanics Overuse (dance, high heels) Os Trigonum Hamilton, W.G., Clin. Sports Med., 1988 Steidas Process Evaluation Provocative tests: Heel raise pain at EOR MMT: Up on toes PROM: ankle PF Palpation: tenderness at TCJ posterior capsule Differentiators: Pain on forced PF Patients with PI will

OVERUSE gastroc./soleus/ AT to compensate Achilles tendinitis 7 02/23/2020 Posterior Impingement En pointe Releve 8 02/23/2020 Posterior Impingement Os Trigonum 9

02/23/2020 Posterior Impingement Ganglion Cyst Talar Stress Fracture 10 02/23/2020 Flexor Hallucis Longus Tendinitis Pain at: Plantar MTPJ Medial longitudinal arch Antero-medial calcaneus (?PF) Retro-malleolar (medial) Pathomechanics Forefoot varus Ankle valgus Knee valgus

Tissue compliance Shortened use (ballet, high-heels) Overuse (jumping, up on toes) Evaluation MMT: *1st MT plantarflexion PROM: *ankle DF with 1st MT DF Palpation: *tenderness along FHL Differentiators: 1. Surface anatomy 2. MMT of 1st MT 3. Test-treat-re-test 11 02/23/2020 Talar Stress Fracture and OCD Pain at: Posterior TCJ Pathomechanics

Overuse (jumping, running) Evaluation Provocative tests: Forced PF Downhill walk MMT: N/A PROM: ankle PF Palpation: Tenderness at: Posterior TCJ Differentiator: 1. Catching during running and walking 02/23/2020 12 Talocrural Malalignment

Pain at: Retro-malleolar Posterior TCJ Pathomechanics Repetitive deceleration Evaluation Provocative tests: Forced PF Pointe MMT: N/A PROM: ankle PF Palpation: N/A Mixed: talus PA glide is: Therapeutic Diagnostic Differentiators: 1. Negative MMT 2. + forced PF

02/23/2020 13 Normal Ankle Mechanics - Dorsiflexion Talus glides posteriorly, externally rotates and tilts laterally Fibula supero-posterior glide, lateral translation Proximal TFJ Fibula moves anterolaterally and superiorly and rotates. Peroneus longus plantarflexes 1st ray Peroneals (longus and brevis) transfer weight from lateral to medial forefoot. Denegar and Miller, 2002) 02/23/2020 14 Normal Ankle Mechanics - Plantarflexion Talus glides anteriorly, internally rotates and tilts medially

Fibula infero-anterior glide, medial translation Proximal TFJ Fibula glides Superoposteromedially with pronation, and Inferoanterolaterally with supination. Denegar and Miller, 2002 02/23/2020 SCENARIO 2: PLANTAR FASCIITIS FHL TENDINITIS SESAMOIDITIS 15 02/23/2020 Plantar Fasciitis Pain at: Tenoperiostial junction (TPJ) Pathomechanics

Forefoot varus Pronation Knee valgus Overload myofascial compliance Tissue adaptation Thickening Inflammation Pain Water-binding capacity Examination Alignment: Hindfoot Forefoot Standing posture: Knee Foot and ankle PROM: Tight Achilles/gastroc/soleus Palpation: greatest at TPJ

16 17 02/23/2020 Flexor Hallucis Longus Tendinitis Pain at: Plantar MTPJ Medial longitudinal arch Antero-medial calcaneus (?PF) Retro-malleolar (medial) Pathomechanics Forefoot varus Ankle valgus Knee valgus Tissue compliance Shortened use (ballet, high-heels) Overuse (jumping, up on toes) Evaluation MMT: *1st MT plantarflexion

PROM: *ankle DF with 1st MT DF Palpation: *tenderness along FHL Differentiators: 1. Surface anatomy 2. MMT of 1st MT 3. Test-treat-re-test 02/23/2020 18 Sesamoiditis Pain at: Plantar aspect of first ray Pathomechanics Forefoot varus Knee valgus Tight/overactive hip adductors Weak/inhibited hip abductors and external rotators

Poor myofascial compliance Shortened use (ballet, Irish dance high-heels) Overuse (jumping, up on toes) Evaluation Provocative test: Heel raise Hopping MMT: 1st MT plantarflexion PROM: ankle DF with 1st MT DF Palpation: *tenderness at sesamoids Differentiators: 1. Surface anatomy 2. Localized pain 02/23/2020 SCENARIO 3:

ANKLE INSTABILITY 19 20 02/23/2020 Chronic Ankle Instability (CAI) Alteration in TCJ arthrokinematics Reduced dorsi-flexion ROM Decreased postural control Arthrogenic inhibition (Wilkstrom and Hubbard, 2010) (Drewes et al 2009) (Wilkstrom et al, 2009; Arnold et al, 2009; Munn et al, 2010) (McVey et al, 2005)

Altered spinal reflex modulation patterns in soleus (Sefton et al, 2008) 02/23/2020 Possible Causes Greater Q-Angle in females Ligament laxity Patella laxity Greater quadriceps:hamstring strength ratio Hormonal effects on ligament tensile strength Landing technique Poor shoe design Tightness/ activation adductors Weakness/inhibition or fatigue: Gluteus maximus and deep external rotators Neuromuscular activation lag (Chappel et al, 2005) Impaired balance (Greig and Wilker-Johnson, 2007) Reduced coordination (Coventry et al, 2006) and proprioception

21 02/23/2020 FOOT AND ANKLE EXAMINATION 22 02/23/2020 Examination 1. Alignment a. Foot alignment 2. Quick Active Tests a.

Squat a. b. Double Single Hop c. Lunge b. 3. Range of Motion a. Dorsiflexion b. Plantarflexion 4. Palpation a. FHL retromalleolar, plantar, retrofibular b. Knot of Henry c. Achilles soleus component d. Talocrural joint - posterior 23

24 02/23/2020 Chief Complaint Differential Diagnosis Algorithm Posterior Ankle Pain Provocative Tests Yes Palpation Treatment No

PF TCJ Capsule XFM: TCJ caps Balance Plyometrics Yes No ISQ DF No Ankle Ev.

+PF MMT Yes Yes Heel Raise No PA Mobs Windlass PNF Balance Plyometrics 1st MTJ PF MMT No

Peroneus Longus Yes XFM: PL MFR: P Ecc. strength No Yes Yes FHL Yes XFM: FHL MFR: FHL Ecc. strength

No Achilles (soleus) Yes Yes XFM: Achilles MFR: G&S Ecc. strength 02/23/2020 Treatment Joint mobilization (physiological and accessory) to: Restore joint mobility (DF) Improve functional stability (Hoch and McKeon, 2011), and Relieve pain Soft tissue treatments to:

Fascia Ligament/capsule Muscle Tendon PNF to ankle musculature to: Inhibition: decreased motoneuron drive Facilitation: increased motoneuron drive Proprioception: Wobble board, BOSU Perturbations Intrinsic strengthening 25 02/23/2020 26 Deep Transverse Friction Massage

Tendons on a Stretch 2. Muscles relaxed 3. Structures 1. 1. 2. 3. 4. Achilles FHL Peroneus longus Posterior capsule 02/23/2020 27 Soft Tissue Mobilization Ligamentous mechanoreceptors postural control

Deep transverse frictions Fascial manipulation Improved: Mechanoreceptor activation Facilitation of spinal reflexes Greater tensile strength Improved perfusion 02/23/2020 28 Joint Mobilization 1. Talocrural PA a. b. c. Prone Supine

Self-applied 2. Talocrural AP a. b. c. Prone Supine Self-applied TCJ mobilization (Maitland) improves DF ROM and SLS postural control (Hoch and McKeon, 2011) 29 02/23/2020 Joint Mobilization Direction

<60 degrees of active ROM: Accessory =>60 degrees of active ROM: Physiological Grade Identify at least one Comparable Sign (CS) Rhythm Dose I II II+ III IV 02/23/2020 Talo-Crural AP Patient Supine, ankle neutral.

Therapist Places right hand over dorsum of foot and left hand under calcaneus. Mobilization Applies distraction to the talocrural joint and applies AP pressure to the foot using the bed as a counter force May use strap to apply long axis distraction Grades I to IV Repeat for 30 seconds, then check CS 30 02/23/2020 31 Dynamic Stability from Proprioceptors Fascia Golgi end organs (90%), slow -mn firing rate,

Paccinian and Pacinoform : rapid response to changes in pressure and vibration Ruffini : slow response to pressure change Type III (unmyelinated) and type IV (myelinated) free nerve endings: mechanoreceptors Ligament Golgi end organ function as anti-gravity mechanorepceptors Type III and IV free nerve endings: mechanoreceptors Muscle spindle - gamma afferent from intrafusal fibers: length, tension. Tendon Golgi tendon organ: respond to slow stretch by slowing the -mn firing rate Less than 10% of GT receptors found in tendon Instability Persistent faulty firing from receptors 02/23/2020

Proprioceptive Rehabilitation Posture Tandem Single leg stance Surface Firm ground Foam BOSU Wobble Board Perturbations Eyes closed Head turn Arms to the side Weight passing side-to-side Arm sagittal circles with eye tracking Walking side-to-side Simulation 32

02/23/2020 Plyometrics Reduced load Total Gym Pool Shuttle Progress to full load Two feet to two feet One foot to one foot Two feet to one foot Two foot take off, single foot landing 33 02/23/2020 Plyometrics 34

02/23/2020 Questions 35

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