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Talar Dome Fracture – Blog by Louise Holland

Is your ankle pain persisting after a badly sprained ankle injury?

The Talus is one part of the bones in your ankle. It is the highest bone of the foot, located just below the point where the lower leg unites with the foot.
The Talar Dome refers to the upper rounded part of the talus that joins upward with the bones of the lower leg tibia and fibula to form the ankle joint. The talus not only plays a vital role in the movement of the ankle joint required during walking, running, jumping and in all the activities that we perform on our feet, but also supports the body weight as we stand or walk.

Like the joint surfaces of all the bones forming a moveable joint, the upper surface of the talar dome is also covered with cartilage that reduces the friction between the two bone surfaces during movement at the joint. For this reason, fractures of talar dome can also be called:
• Osteo (bone) chondral (cartilage) fractures: that is fractures involving both bone and cartilage, or,
• Trans (through) chondral (cartilage) fractures: As the injurious force causing the fracture is transmitted through the cartilage to the underlying bone.

Causes:

Talus fractures are not a common occurrence; however, their incidence is greater in active young adults such as athletes or in postmenopausal women. Men are twice as likely to acquire an ankle fracture.
A talar dome fracture can be caused by:
• An inversion ankle injury (the foot rolls inwards accidentally), about 2%-6% of acute ankle sprains are associated with a talar dome fracture.
• A direct injury to the ankle (such as an object hitting where the talus joins the leg bones)
• A combined inversion injury with a compression element of the joint into the ground.
A fracture usually involves the shoulder of the talar dome on either the inner side or the outer side. Both sides are only rarely involved simultaneously. Fractures of the inner talar dome may occur even in the absence of trauma for reasons which are still unclear.

Mechanism of injury:

(Stages of fracture)
A transchondral fracture occurs when a damaging blow hits the cartilage surface of the talar dome and is transmitted to the underlying bone, causing fracture of the bone and/or cartilage. There are four different categories of fractures to the Talar dome:
Stage I: This involves the force hitting the cartilage-covered surface of the talar dome. The cartilage remains intact, while the underlying bone collapses under the force, leading to an irregular joint surface. This irregular surface causes pain during joint movement.
Stage II: This involves cracking (chipping) of cartilage as well as bone
Stage III: The fractured fragment detaches completely from the bone, but still remains in its place
Stage IV: The fractured fragment becomes loose and gets displaced into the joint space.

As a result of the damaged joint surface and/or the fractured fragments present in the joint space, there is pain and inflammation and the movement at the joint becomes painful and restricted.
Moreover, injury to the bone may damage its blood supply, leading to aseptic necrosis of the bone (death of bone cells in the absence of an infection). The overlying cartilage derives its nutrition from the fluid in the joint space and therefore does not suffer from a lack of blood flow.
Aseptic necrosis is a major factor delaying the healing of talar dome fractures.

Symptoms:

A great number of talar dome fractures usually occur with an ankle sprain, a result of an accidental inward twist of the foot.
Along with the pain of damaged ligaments, there is a deep-set pain in the ankle, which persists for longer, even after the initial intense pain has subsided.
Return to activity leads to recurrent pain and swelling. Especially in any weight bearing activities.
There may be stiffness of the joint (a locking sensation during movement) and crepitance (a grating or crackling sound on movement).
There may be weakness and instability of the joint.

Diagnosis:

Talar dome fractures are often missed at the initial examination following an ankle sprain or injury.
The treatment given for the sprain or injury usually fails to treat the unidentified fracture. The result is a persistent deep pain in the ankle and recurrent swelling with activity.
Follow-up X-rays, about 4 to 6 weeks after injury, should be taken to rule out any fractures of the talar dome.
Moreover, in the case of fracture of the outer side of the talar dome there is tenderness in front of the outer bump of the ankle with the foot bent downwards.
However, if there is tenderness behind the inner bump of the ankle with the foot bent upwards, the inner side of the talar dome is involved.
If initial X-rays do not show any evidence of fracture despite the signs and symptoms, a bone scan, CT scan or MRI may be advised. These diagnostic tools are especially helpful in diagnosing Stage I osteochondral defects and in assessing the extent of the damage to the bone.

Treatment:

Conservative Treatment:

The treatment of a talar dome fracture is often delayed due to late diagnosis. However, it is recommended to initiate the treatment with a conservative approach immediately if you suspect, which includes:
• Rest
• Immobilizing the joint using an ankle brace or walking cast (moonboot) for about six to ten weeks
• Using crutches to keep the load off the fractured bone
• Pain killers
Non-displaced fractures of the talar dome usually heal with this treatment approach. However, even if conservative treatment fails to resolve the problem, it does not complicate the problem any further nor does it cause any problem if an operation is planned afterwards.
Surgery is required for:
• Healed fractures leaving a defect on the cartilage covering the joint surface of the bone; this causes pain and instability of the joint
• Displaced fractures (fractured fragments dislocated into the joint space)
Once the immobilizing cast is removed, the condition of the bone should be re-evaluated. If there are any symptoms of joint dysfunction such as:
• A locking of the ankle joint
• Instability of the joint
• Pain in the joint (that goes away with injecting a local anesthetic)
An MRI or other diagnostic tools should be employed to check for the displaced fractured fragments and for any residual defects in the cartilage covering the joint surface of the bone.
Surgical treatment involves:
Arthroscopy (repairing the damaged bone with the help of an arthroscope):
This involves making a small incision through which an arthroscope (a small tube with an optical system to look into the joint, attached to a monitor or TV screen) is inserted to clean the surface of damaged cartilage by grinding away the defect. In some cases, this arthroscopic procedure is accompanied by drilling the bone under the cartilage to stimulate blood flow to the area and speed up healing and to prevent aseptic necrosis of the bone.
                                                                                        Stage I and II fractures usually require arthroscopy with or without drilling of the underlying bone

Internal fixation using pins and screws

Open Reduction and Internal Fixation:

This involves opening the skin for reduction (fixation or correction of a fracture) with the help of internal fixation (joining fractured fragments of bone using pins and screws placed inside the bone).
This requires a relatively larger skin incision than is used in arthroscopy and may involve the placement of a graft to rectify the shape of the damaged talar dome.
Stage III and IV fractures do respond to the arthroscopic approach, but often require open surgery and graft placement.
After complete healing of the fracture, proper rehabilitation is required to improve the strength and stability of the joint as well as its range of motion.
In our clinics, we can provide special tests and assess to differ if you have a lateral ankle sprain or a talar dome fracture. We can help in the rehabilitation process pre and post surgery if required.

So if you’ve had a recent ankle fracture make an appointment below at one of our clinics at Total Physiocare Heidelberg, Reservoir, Camberwell and Footscray

Book an appointment today for your assessment!

 

Plantar Fasciitis

What is Plantar Fasciitis? – Blog By Emily Shortal

This common foot condition is pronounced – “Plan-tar   fash–ee-eye-tus”.

Plantar fasciitis is the most common cause of heel pain. Repetitive stress to the plantar fascia can cause pain. It is a thick, fibrous ligament on the sole of the foot running from the toes to the heel bone. This ligament supports the arch of your foot and helps absorb shock when walking. The plantar fascia is not very elastic, hence when too much repetitive stress or traction is placed on it, micro-tearing can occur and result in pain and inflammation.

plantar1

 

What is a heel spur?

A heel spur (or osteophyte) is a calcium deposit causing a bony protrusion on the bottom side of the heel bone. Heel spurs are commonly associated with plantar fasciitis.

plantar2

What are the symptoms?

Heel pain is more intense with the first steps in the morning or after a period of sitting. The plantar fascia tightens and shortens during rest, but then is placed on traction and stretched once weight-bearing. This pain is usually sudden and sharp, often described as a stabbing pain. After a period of walking, the plantar fascia loosens and the pain can change to a dull ache, or disappear completely. However after walking or standing for a prolonged period the pain will return.

 

What are the risk factors?

The following factors increase the risk of plantar fasciitis:

  • Sports: especially repetitive impact activities such as running and jumping places excess strain on the arch of the foot. Ballet, and dancers in general are also prone to plantar fasciitis for this reason.
  • Foot biomechanics: particularly those who are flat footed or with a naturally high arch, whereby there is a great degree of tightness in plantar fascia. Additionally, having pronated (rolled in) feet.
  • Ageing: plantar fasciitis is most common amongst the over 50’s demographic due to muscle weakness and tightness in the ligaments. Additionally over time the natural protective fat pad under the heel thins.
  • Overweight: excess weight places greater tractional forces on the plantar fascia, causing more trauma overtime.
  • Pregnancy: from both increased weight and ligament laxity due to pregnancy hormones
  • Occupation: those who are on their feet for prolonged periods because of work, particularly if standing on hard surfaces or with unsupportive footwear.

plantar4

How do I get rid of my plantar fasciitis?

No single treatment works best for every case of plantar fasciitis, as differing contributing factors must be addressed. Hence attending Physiotherapy to identify and address these factors is crucial.

Common treatment methods include:

  • Anti-inflammatory techniques, ice
  • Stretching and massage
  • Exercises to strengthen the plantar fascia
  • Shoe recommendations; good arch support is essential!
  • Taping, shoe inserts or orthotics to support your plantar fascia
  • Gel cups to cushion the heel bone
  • Strassbourg sock/night splint to prevent tightening overnight
  • Cortisone injection: a powerful anti-inflammatory, usually only recommended once less invasive treatment has been unsuccessful. Bear in mind that a cortisone injection does not address the root cause of the condition, hence your symptoms can often return if the contributing factors are not addressed are supported with other treatment methods.

Our team at Total Physiocare in Reservoir, Heidelberg, Camberwell & Footscray are ready to help rid you of heel pain once and for all!

Book an appointment today for your assessment!

Blog By Emily Shortal (Physiotherapist)

plantar3

Stress Fractures

What are stress fractures? – Blog By Rhian Davies

A stress fracture is an overuse injury where there is an overload of stress to the bone resulting in a tiny crack.  This occurs when the stress of repetitive loads overwhelms the ability of the bone to repair itself and these cracks begin to occur within the bone structure.

Causes

Stress fractures are often the result of increasing the amount or intensity of an activity too rapidly. Can also be due to an impact of an unfamiliar surface, improper equipment or increased physical stress.

Where do stress fractures occur?

Weight bearing bones of the body such as:

  • Metatarsal bones of the foot
  • Navicular bone in the foot
  • Calcaneus (heel bone)
  • Tibia (shin bone)
  • Femur (thigh bone)
  • Pelvis
stress-fracture
Common bones where stress fractures occur

 

Most common in the weight-bearing bones of the lower leg and foot with more than 50% of all stress fractures occurring in the lower leg.

Risk Factors:

  • Repetitive sporting activities ie. Running, Basketball, Tennis, Dancing
  • Sudden increase in activity ie. Intensity, duration or frequency of training sessions
  • Poor foot posture ie. Flat feet or high arches
  • Females more likely than males
  • Osteoporosis or weakened bones
  • Previous stress fractures
  • Lack of nutrients ie. Lack of Vitamin D and calcium

running

Symptoms:

  • Symptoms can vary widely but a common complaint is pain with activity which subsides with rest.
  • Pain that gradually worsens over time when continuing the aggravating activity.
  • Swelling and tenderness may also be present around the area of pain.

sports

Diagnosis:

A stress fracture can sometimes be diagnosed through a subjective and physical examination but often imaging is needed to confirm the diagnosis.

  • MRI: Can visualize stress fractures within the first week of injury
  • Bone Scan: Can detect problems in bones but not specific to stress fractures
  • X-ray: Not seen on regular x-rays for at least several weeks up to over a month from the initial onset of pain.

x-ray-of-foot

Management

If diagnosed with a stress fracture, your physiotherapist will be able to prescribe the correct management specific to you and your needs. In most cases, the initial management will include a period of rest to allow the stress fracture to heal, this may involve the use of crutches or wearing a weight bearing boot in moderate to severe cases, to reduce the bone’s weight bearing loads.

Rehabilitation and strengthening as well as a gradual return to activity are extremely important to prevent or reduce the likelihood of re-injury. Your physiotherapist will be able to develop a specific program to enable you to safely and efficiently return to your activity or sport.

stretching

Tips to help prevent stress fractures:

  • Proper footwear for specific type of exercise
  • Gradual build up when starting a new exercise program
  • Walk/warm up prior to running
  • Stretch + strengthen calf muscles
  • Cool down properly after exercise

At Total Physiocare we specialise in the accurate diagnosis, management and return to activity or sport for clients presenting with stress fractures.

Book an appointment today for your assessment!

Blog By Rhian Davies (Physiotherapist) 

Ankle Sprains

What is a sprained ankle? – Blog By Kara Giannone

An ankle sprain occurs when your ankle ligaments are overstretched. They can vary greatly in severity from a minor “rolled ankle” to a complete ligament rupture with or without bone tendon or muscle injury. They are graded as 1, 2 or 3 depending on the severity.

 ankle-sprain-1

Anatomy of the ankle

The ankle, referred to as the talo-crural joint or true ankle joint, consists of three bones – the tibia, fibula and talus and is responsible for plantarflexion and dorsiflexion of the ankle. The subtalar joint lies underneath the true ankle joint and is the articulation between the talus and calcaneus. It assists the talo-crural joint in inversion and eversion. Most ankle sprains occur from an inversion mechanism of injury (rolled in).

anatomy

The most commonly injured ligaments of the ankle are the lateral ligaments which sit on the outside of the ankle. These include the anterior talofibular ligament, calcaneofibular ligament and posterior talofibular ligament. The ligament on the inside of the ankle is called the deltoid ligament which is much stronger and hence more difficult to injure.

anatomy3

High ankle sprains refer to injury to the inferior tibiofibular ligaments and syndesmosis which bind the tibia (shin bone) and fibula (calf bone) together above the ankle. A high ankle sprain is a much more debilitating injury, requiring a longer recovery time.

What causes an ankle sprain?

Ankle sprains occur most commonly by a sudden twisting or rolling action of your ankle often on unstable irregular surfaces. The ligaments affected is determined by the direction the foot rolls. The most common ankle sprain is the ligament on the side which occurs when the foot is turned in as shown below.

Certain factors can put a person at greater risk of spraining their ankle including poor footwear, previous injury, reduced strength, poor biomechanics or poor balance receptors.
rolled-ankle

What are the symptoms of a sprained ankle?

  • The mechanism of rolling your ankle is a clear indicator that you are likely to have sprained your ankle
  • You may hear a popping or cracking sound at the time of injury
  • The injured ligaments will be quite tender to touch in that initial phase
  • Swelling and bruising
  • Generalised ankle pain
  • In the cases of a severe ankle sprain, you may have difficulty walking and may require the use of crutches to mobilise.

How is a sprained ankle diagnosed?

Physiotherapists will take a thorough history and conduct a comprehensive clinical examination to effectively assess and diagnose ankle sprains. Furthermore, to exclude certain fractures or ligamentous injuries, it may be required to refer for imaging like a X-RAY, MRI or CT scan.

 

Management of an ankle sprain

A person who sprains their ankle is up to 70% more likely to re-sprain their ankle without the correct post-injury rehabilitation.

In the initial 72 hours post injury, it is essential to use the principles of R.I.C.E – This include rest, ice the affected area every 2 hours for 20 minutes, compress the ankle with a compression bandage and elevate in order to manage pain and swelling.

Physiotherapy is crucial in the management of ankle sprains. It is important in managing pain and improving range of movement, strength, proprioception, balance and assist in return to your pre-morbid level of activity.

Physiotherapy treatment may include:

  • Education
  • Gait re-training
  • Biomechanical correction
  • Exercise prescription including sport specific training
  • Taping
  • Soft tissue massage
  • Mobilisations
  • Sport specific training
  • Electrotherapy and more!

 

At Total Physiocare Heidelberg, Reservoir, Camberwell and Footscray, we specialise in accurate assessment, management and return to sport or level of activity for clients presenting with ankle sprains. 

Book an appointment today for your assessment!

Blog post by Kara Giannone

What is a tendon and Tendinopathy?

What is a Tendon and Tendinopathy?

A tendon is a strong band of fibrous tissue that connects a muscle to the bone. The role of a tendon is to transmit force between the muscle and bone and act a shock absorber especially in the lower limb.

Pathology or injury to a tendon is referred to as a tendinopathy. Colloquially, a tendinopathy can be described as an overuse injury to a tendon. Especially in the athletic population, tendinopathies can be extremely debilitating chronic injuries which adversely affect an athletes performance. Historically these conditions are poorly managed without physiotherapy guidance.

tendon
Anatomy of a Tendon

Note: previously the above pathology was referred to as ‘tendinitis’, however histopathological studies have indicated a lack of inflammatory cells in patients with tendon pain. The term tendinosis can also be utilised to describe overuse pathology of a tendon.

Common Sites of Tendinopathy:

Common sites for tendon pain include:

  • Achilles (heel) tendinopathy
  • Patella (knee) tendinopathy
  • Adductor (groin) tendinopathy
  • Rotator cuff (shoulder) tendinopathy
  • Elbow (Tennis elbow or golfer’s elbow)
  • Wrist/Thumb (De Quervein’s)

knee tendon shoulder tendon

Symptoms:

The clinical symptoms of clients with overuse tendon pain include:

  • Pain free at rest and initially becomes more painful with use
  • Pain following exercise or activity
  • Pain the morning following exercise/activity, especially upon rising.
  • Athletes report an ability to “run through” the pain or the pain disappears once they “warm-up”. Despite this the pain returns (often worse) once they cool down
  • The athlete/client is able to continue to train/function fully in the early stages of the condition, which likely interferes with the healing process
  • Examination highlights local tenderness
  • Reduced muscular strength or function is apparent secondary to pain

Stages of Tendon Pain:

As proposed by tendon experts Jill Cook and Craig Purdam, tendon pathology should be considered as a continuum. In this light the early intervention can ‘reverse’ the symptoms and pathology of an inappropriately loaded tendon.

Stage 1:          Reactive Tendinopathy           An acutely overloaded tendon

Stage 2:          Tendon Dysrepair                   A worsening of tendon pathology with breakdown of                                                                the matrix of the tendon

Stage 3:          Degenerative Tendinopathy   Chronic tendon pain with areas of cell death and                                                                               collagen and matrix breakdown within the tendon.

tendon pathway

Risk Factors:

Risk factors for tendinopathy include:

  • Increased or excessive load on a tendon
  • Muscular weakness
  • Poor biomechanics or load strategies
  • Inappropriate extrinsic factors (ie shoe wear, ground surfaces, etc)

Physiotherapy and management:

Physiotherapy management of tendon pain is dependant on the location and role of that tendon (ie the management of tendinopathy’s in the upper limb differs from that in the lower limb). Several strategies will be employed by your treating physiotherapist to aid in the tendon recovery as highlighted in the continuum above. These include:

– Load management

– Static strengthening

– Progressive strengthening

– Biomechanical corrections

  • Equipment prescription (ie appropriate runners)
  • Taping or bracing as required

It is worth noting the below strategies have been shown to be detrimental in the recovery process of  tendinopathies:

  • Complete rest
  • Ignoring the pain
  • “Stretching” of the tendon

– “Compression” of the tendon

  • Massage of the tendon (note massage of the attached muscle may be beneficial)
  • Passive approaches (ie injections – especially without the addition of appropriate exercise program)
  • Not adhering to exercise and load advice as guided by your therapist

Evidence supports the fact that exercise based rehabilitation is the best treatment for tendon pain. At Total Physiocare we specialise in the accurate diagnosis, management and return to activity or sport for clients presenting with tendinopathy. Call us now to make an appointment.

jumpingcatching theraband

Blog by Christian Bonello (Physiotherapist)

What is Sever’s Disease?

SEVER’S DISEASE

Sever’s disease or “calcaneal apophysitis” is a common condition affecting children. It is characterized by an insidious onset of heel pain that usually worsens rapidly. It can be develop in any child but more commonly affects physically active children, and is more common in boys. It develops just before puberty and is most often seen in girls aged 9-11 and boys aged 10-12.

Despite being a fairly common condition, many parents are unaware of the signs and symptoms, the management on the condition and the long term prognosis for their child. This blog will help explain the condition and pathways of management used by physiotherapists.

What is Sever’s Disease?

Sever’s Disease is inflammation and subsequent pain in the growth plate or “epiphyseal plate” in the heel of the foot. Growth plates are found at the ends of developing bones and contain cartilage cells that form into adult bone. This process occurs during a growth spurt in children and is how their bones grow.

severs

When this process is occurring the growth plates are weaker as they have not fully formed into adult bones. In this period of rapid growth, a child’s bones grow faster than their muscles causing them to be become tight. In the instance of sever’s disease the calf muscle and Achilles tendon is pulled tight resulting in pain and inflammation where it attaches to the weakened bone on the heel.severs2

Signs and Symptoms

  • Pain in the heel area or achilles tendon on one or both feet
  • Pain during and/or after exercise
  • Worsened by impact activities like running, jumping, landing
  • Worsens with exercise often improves with rest
  • Swelling at the heel and can be sore to touch
  • Calf muscle tightness
  • Limping or walking on toes

Factors that can contribute to developing Sever’s

  • Being physically active
  • Wearing inappropriate shoes during sport
  • Playing sport on hard surfaces
  • Pronated feet
  • A flat or high arch (both cause tightening of the Achilles tendon)

Diagnosing Sever’s Disease

A physiotherapist or podiatrist can usually diagnose Sever’s from asking questions and a simple assessment of the foot.  An x-ray is not necessary but can show changes to bone to help diagnose and also rule out other possibilities like a fracture.

Treatment

Initial management:

  • Rest from activity until pain resolves
  • Ice post exercise or end of day
  • Stretching for calf muscle and achilles
  • Wearing well fitting supportive footwear
  • Heel lift in shoes to offload the tight Achilles tendon
  • In more severe cases when bone is heavily disrupted your child may be prescribed a cam boot by their physiotherapist or podiatrist. These are worn for a few weeks to limit weight bearing through the foot and allow the bone and growth plate to properly heal

Once symptoms have settled your child can return to activity gently. Your physiotherapist will usually advise you to begin with lighter activity and progress to higher impact activity to ensure the growth plate is not aggravated causing a flare up of symptoms.

Prognosis

Once the child’s initial rapid growth slows, symptoms generally resolve with no long term effects. Flare ups can occur over months during puberty but are only self limiting, meaning they are temporary and will settle with rest. If the child continues to overload the foot with activity and “push through the pain” there is a risk of malformation of the growth plate into adult bone, however this is uncommon and if treated properly will not result.

Does your child have Severs? Book in with our team at Total Physiocare now!

Blog post by our Physiotherapist Briony Barry