Diagnosis and management of the painful ankle/foot part 1: clinical anatomy and pathomechanics

Manual therapy in joint and nerve structures combined with exercises in the treatment of recurrent ankle sprains: A randomized, controlled trial

BACKGROUND

Recurrent ankle sprains often involve residual symptoms for which subjects often perform proprioceptive or/and strengthening exercises. However, the effectiveness of mobilization to influence important nerve structures due to its anatomical distribution like tibial and peroneal nerves is unclear.

OBJETIVES

To analyze the effects of proprioceptive/strengthening exercises versus the same exercises and manual therapy including mobilizations to influence joint and nerve structures in the management of recurrent ankle sprains.

STUDY DESIGN

A randomized single-blind controlled clinical trial.

METHOD

Fifty-six patients with recurrent ankle sprains and regular sports practice were randomly assigned to experimental or control group. The control group performed 4 weeks of proprioceptive/strengthening exercises; the experimental group performed 4 weeks of the same exercises combined with manual therapy (mobilizations to influence joint and nerve structures). Pain, self-reported functional ankle instability, pressure pain threshold (PPT), ankle muscle strength, and active range of motion (ROM) were evaluated in the ankle joint before, just after and one month after the interventions.

RESULTS

The within-group differences revealed improvements in all of the variables in both groups throughout the time. Between-group differences revealed that the experimental group exhibited lower pain levels and self-reported functional ankle instability and higher PPT, ankle muscle strength and ROM values compared to the control group immediately after the interventions and one month later.

CONCLUSIONS

A protocol involving proprioceptive and strengthening exercises and manual therapy (mobilizations to influence joint and nerve structures) resulted in greater improvements in pain, self-reported functional joint stability, strength and ROM compared to exercises alone.

Thoracic outlet syndrome: a controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis

Thoracic outlet syndrome (TOS) is a frequently overlooked peripheral nerve compression or tension event that creates difficulties for the clinician regarding diagnosis and management. Investigators have categorized this condition as vascular versus neurogenic, where vascular TOS can be subcategorized as either arterial or venous and neurogenic TOS can subcategorized as either true or disputed. The thoracic outlet anatomical container presents with several key regional components, each capable of compromising the neurovascular structures coursing within. Bony and soft tissue abnormalities, along with mechanical dysfunctions, may contribute to neurovascular compromise. Diagnosing TOS can be challenging because the symptoms vary greatly amongst patients with the disorder, thus lending to other conditions including a double crush syndrome. A careful history and thorough clinical examination are the most important components in establishing the diagnosis of TOS. Specific clinical tests, whose accuracy has been documented, can be used to support a clinical diagnosis, especially when a cluster of positive tests are witnessed.

The impact of rheumatoid foot on disability in Colombian patients with rheumatoid arthritis

BACKGROUND

Alterations in the feet of patients with rheumatoid arthritis (RA) are a cause of disability in this population. The purpose of this research was to evaluate the impact that foot impairment has on the patients' global quality of life (QOL) based on validated scales and its relationship to disease activity.

METHODS

This was a cross-sectional study in which 95 patients with RA were enrolled. A complete physical examination, including a full foot assessment, was done. The Spanish versions of the Health Assessment Questionnaire (HAQ) Disability Index and of the Disease Activity Score (DAS 28) were administered. A logistic regression model was used to analyze data and obtain adjusted odds ratios (AORs).

RESULTS

Foot deformities were observed in 78 (82%) of the patients; hallux valgus (65%), medial longitudinal arch flattening (42%), claw toe (lesser toes) (39%), dorsiflexion restriction (tibiotalar) (34%), cock-up toe (lesser toes) (25%), and transverse arch flattening (25%) were the most frequent. In the logistic regression analysis (adjusted for age, gender and duration of disease), forefoot movement pain, subtalar movement pain, tibiotalar movement pain and plantarflexion restriction (tibiotalar) were strongly associated with disease activity and disability. The positive squeeze test was significantly associated with disability risk (AOR = 6,3; 95% CI, 1.28-30.96; P = 0,02); hallux valgus, and dorsiflexion restriction (tibiotalar) were associated with disease activity.

CONCLUSION

Foot abnormalities are associated with active joint disease and disability in RA. Foot examinations provide complementary information related to the disability as an indirect measurement of quality of life and activity of disease in daily practice.

Diagnosis and Management of the Painful Ankle/Foot. Part 2: Examination, Interpretation, and Management

Diagnosis, interpretation, and subsequent management of ankle/foot pathology can be challenging to clinicians. A sensitive and specific physical examination is the strategy of choice for diagnosing selected ankle/foot injuries and additional diagnostic procedures, at considerable cost, may not provide additional information for clinical diagnosis and management. Because of a distal location in the sclerotome and the reduced convergence of afferent signals from this region to the dorsal horn of the spinal cord, pain reference patterns are low and the localization of symptoms is trustworthy. Effective management of the painful ankle/foot is closely linked to a tissue-specific clinical examination. The examination of the ankle/foot should include passive and resistive tests that provide information regarding movement limitations and pain provocation. Special tests can augment the findings from the examination, suggesting compromises in the structural and functional integrity of the ankle/foot complex. The weight bearing function of the ankle/foot compounds the clinician's diagnostic picture, as limits and pain provocation are frequently produced only when the patient attempts to function in weight bearing. As a consequence, clinicians should consider this feature by implementing numerous weightbearing components in the diagnosis and management of ankle/foot afflictions. Limits in passive motion can be classified as either capsular or non-capsular patterns. Conversely, patients can present with ankle/foot pain that demonstrates no limitation of motion. Bursitis, tendopathy, compression neuropathy, and instability can produce ankle/foot pain that is challenging to diagnose, especially when they are the consequence of functional weight bearing. Numerous non-surgical measures can be implemented in treating the painful ankle/foot, reserving surgical interventions for those patients who are resistant to conservative care.