musculoskeletal injury

1. OVERUSE
SYNDROME AND
NONOPERATIVE
MANAGEMENT
FOR ANKLE JOINT
QURATULAIN MUGHAL
BATCH IV
DOCTOR OF PHYSICAL THERAPY
ISRA UNIVERSITY

2. CONTENTS
• OVERUSE SYNDROME
• BIOMECHANICAL STRESSES
• PREDISPOSING FACTORS
• REALATED PATHOLOGIES
• CAUSES
• MANAGEMENT
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3. OVERUSE SYNDROME
• Also described as degenerative without inflammation.
• Occurs due to repetitive microtrauma, biomechanical stress
or overload.
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4. BIOMECHANICAL STRESSES
• Obesity.
• Work habits.
• Faulty alignment of lower extremity.
• Muscles imbalance or fatigue.
• Changes in the exercise or functional routines.
• Training errors.
• Improper foot wear for the ground.
• Functional demand placed on feet.
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5. PREDISPOSING FACTORS
• Painful syndromes is due to excessive pronation of subtalar joint
during weight-bearing activities.
CAUSES OF PRONATION:
 Excessive joint mobility.
 Leg length discrepancy.
 Femoral anteversion.
 External tibial torsion.
 Genu valgum.
 m/s flexibility.
 Strength imbalance in lower extremity.
 Hypomobile gastrocnemius-soleus complex.
Pronation is the
combination of
dorsiflexion, eversion
and abduction
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6. RELATED PATHOLOGIES
1. HEEL PAIN
2. TENDINOSIS, TENDONITIS &
TENOSYNOVITIS
3. SHIN SPLINTS
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7. HEEL PAIN
• ACFAS published a revised CPG that categorizes mechanical
heel pain as:
1. PLANTAR HEEL PAIN: plantar fasciitis, plantar fasciosis
and heel spur.
2. POSTERIOR HEEL PAIN: insertional achilles tendinopathy
and bursitis.
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8. PLANTAR FASICIITIS
• Pain is felt on plantar aspect of the heel. Where the plantar
fascia inserts on the medial tubercle of the calcaneous.
• The site is very tender to palpation.
• Pain occurs on initial weight-bearing after periods of rest,
then decreases, but returns as weight-bearing activity
increases.
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9. ASSOCIATED IMPAIRMENTS
• Hypomobile gastrocnemius-soleus m/s.
• Plantar fascia pain.
• Restriction when extending the toes creating the windlass
effect.
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10. PREDISPOSING FACTOR
• High body-mass index.
• Inappropriate footwear.
• Flexible flat foot(pes planus).
• High arch(cavus foot).
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Heel spur may
develop at the
site of irritation
on the
calcaneus.
Causing pain
during heel
strike

11. ACHILLES
TENDINOPATHY
ACHILLES
BURSITIS
ACHILLES
TENDINITIS
•PAIN: midportion of tendon 2-
6cm proximal to the insertion on
the calcaneus or at calcaneal
insertion.
•ASSOCIATED IMPAIRMENTS:
decreased ankle dorsiflexion,
decreasesd strength in ankle
plantar flexion, increased foot
pronation.
•RISK FACTORS: obesity, HTN,
DM.
•SYMPTOMS: pain, stiffness in
tendon, decreased ROM initially
but increased with additional
activities.11

12. • TENDINOSIS: degeneration of a tendon from repetitive
microtrauma; collagen degeneration without inflammation.
• TENDONITIS: scarring or calcium deposits in a tendon.
• TENOSYNOVITIS: inflammation of the synovial sheath covering a
tendon.
SIGN AND SYMPTOMS:
• Pain after repetitive activity.
• Pain when resistance is applied on the site of lesion.
• Posterior tibial tendon is common source of pain leads impaired
walking and acquired foot flat deformity.
• Also tibialis tendon, peroneus tendon associated with running,
tennis and basketball.
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13. SHIN SPLINTS
• This term is used to described activity-induced leg pain along the
posteriomedical or anteriolateral aspect of proximal 2/3 of tibia.
• Include different pathological condictions:
 Musculotendinitis.
 Stress fractures of tibia.
 Periosteitis.
 Increased pressure in muscular compartment.
 Irritation of interosseous membrane.
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14. TYPES
A. ANTERIOR SHIN SPLINT
• Overuse of anterior tibialis m/s.
• Most common type of shin splint.
• Hypomobile gastrocnemius-soleus
complex.
• Weak ant.tibialis m/s along with
Foot pronation.
• Pain with active dorsiflexion and
when m/s is stretch in plantar
flexion.
B. POSTERIOR SHIN SPLINT
• Tight astrocnemius-soleus
complex .
• Weak or inflamed post.tibialis m/s
along with foot pronation .
• Associated with posteriomedial
shin splints.
• Pain in passively dorsiflexion with
eversion and active supiation.
• m/s fatigue with vigorous
exercise.
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16. MANAGEMENT(PROTECTION PHASE)
• Immobilization with the cast or splints with the foot slightly
plantarflexion or use of heel lift.
• Custom orthotic inside the shoe may relieve stress.
• Cross-friction massage .
• Electrical stimulation.
• AROM within painfree range.
• Avoid activities that provoke pain.
• Use supportive tapping.
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17. CONTROLLED MOTION AND RETURN TO
FUNCTION PHASES
• When Symptoms will become subacute:
• Examine for deformity.
• Strength all m/s of L/L.
• Stretching exe.
• Improve m/s performance by resistive isometric-dynamic
resistive-close & open chain exe.
• Orthotic devices.
• Educate pt.
• Home plan for pt.
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18. DIAGNOSTIC TEST FOR PLANTAR
FASCIA
• WINDLASS TEST:
 A “windlass” is the tightening of a rope or cable.
 The plantar fascia simulates a cable attached to the calcaneus and the
metatarsophalangeal joints.
 This winding of the plantar fascia shortens the distance between the calcaneus and
metatarsals to elevate the medial longitudinal arch.
 A positive windlass test: heel pain reproduced with passive dorsiflexion of the toes.
CAN PERFORM IN:
• Weight bearing position
• Non weight bearing position
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21. DIAGNOSTIC TEST FOR ACHILLES
TENDON
• Thompson test or Simmonds-Thompson test:
 is used in lower limb examination to test for the rupture of
the Achilles tendon.
PROCEDURE:
 The patient lies face down with feet hanging off the edge of
the bed.
 If the test is positive, there is no movement of the foot
(normally plantarflexion) on squeezing the corresponding
calf, signifying likely rupture of the Achilles tendon.
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23. DIAGNOSTIC TEST FOR SHIN SPLINTS
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24. REFERENCE
• THERAPEUTIC EXECRISE:KISNER AND COLBY
6th edition
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26. ANY QUESTION?????
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