SF Studios had the pleasure to host a talk given by Mr. Matthew Welck, featuring various foot and ankle case studies and their possible management. This talk was particularly insightful and consolidated my knowledge as a therapist on referral schemes. In fact, many times patients are needlessly referred for x-rays or, conversely, have presentations that require urgent referrals and are missed. For this reason, as physiotherapists, it is paramount that we know how to recognise these and refer our patients when appropriate.
When to refer an ankle sprain for an x-ray? The importance of the Ottawa ankle rules
Mr. Welck initially presented two case studies:
54 year old male twisted his ankle and woke up with a very swollen foot. On examination, ankle was very swollen laterally and medially. He also has difficulty weightbearing.
18 year old female rushed down the stairs and twisted her foot. On examination, she has significant swelling and difficulty walking. She also has bruising along the sole and tenderness on the dorsum of the foot.
Mr. Welck explained that the main clinical finding in both these case studies is that both have difficulty weightbearing. This suggests that a fracture may be present and the therapist should immediately review the Ottawa ankle rules depicted below (A). If any of these are present, the patient should be referred for an x-ray. Moreover, Mr. Welck explained that bruising and tenderness in the midfoot could suggest a Lis Franc fracture (B) and is often missed.
When to refer an ankle ligament sprain for an x-ray?
Mr. Welck further outlined the management of ligamentous injuries. Although routinely ligamentous injuries are managed with an aircast boot for 2 weeks, there are some instances in which referral should be done. These include a high ankle syndesmosis sprain, as well as medial and anterior tenderness. This finding could in fact indicate that a fracture could be present. A high ankle syndesmosis sprain usually happens when the foot twists forcefully in dorsiflexion and eversion, giving rise to rupture of the syndesmosis and ATFL (B). This particular injury can be diagnosed with the following: squeeze test, external rotation test as well as palpation of the syndesmosis (A). These tests apply mechanical stress on the structures that could be damaged. Moreover, Mr. Welck specified that when both medial (deltoid) and lateral ligaments are compromised, this gives rise to instability of the ankle and the patient should therefore be referred on this occasion too.
Emergency referrals-Septic arthritis
Mr. Welck explained the importance of being able to identify a medical emergency. He outlined this specific case scenario:
44 yo male with sudden onset of a red, hot and painful joint. He has difficulty weightbearing.
Systemic flu symptoms.
On examination, the joint is irritable and there is difficulty achieving active and passive movement.
The important points not to miss are that the patient is systemically unwell with a sudden onset of a painful joint. Moreover, the patient is resisting PROM (passive range of motion) and has difficulty weight bearing. These are all indicators of septic arthritis which should be managed as a medical emergency. This patient in fact requires urgent wash-out of the joint, as there could be build-up of pus inside the joint as well as intravenous antibiotics. Mr. Welck continued explaining that the patient presentation is very similar to other pathologies such as cellulitis and are summarised below.
- Rapid onset of pain/swelling
- Difficulty weight-bearing
- Resisting PROM
- Patient is systematically unwell
- Slow progression of swelling and pain
- Able to weight-bear
- Breaks/dryness in skin
Achille’s tendon rupture: how to diagnose and treat
Achille’s tendon rupture is probably one of the most famous injuries. Mr. Welck explained how, as therapists, we would assess this particular injury. During the talk, Simmond’s triad was discussed. These are particular tests performed by the physiotherapist to confirm the diagnosis of Achille’s tendon rupture. These tests include: Matle’s test (A) gastrocnemius squeeze test (B), gapping would be visible where the Achille’s tendon should be (C).
The breakthrough: Vacoped and the Swansea protocol
Previously, tendon ruptures were traditionally treated with surgery only. However, the risk of infection and other complications are quite high, such as re-injury. For this reason a new approach has been taken called the Swansea Morriston Achilles Rupture Treatment (SMART) protocol, as seen in (A). The management includes the use of Vacoped, a new generation boot (A). With this specific protocol, there is a particular emphasis on the importance of ultrasound to differentiate between the two different approaches (B). This particular approach significantly reduces re-injury compared to a traditional approach.
Ganglion or tumour? Watch out!
Mr. Welck finally presented another case study. A gentleman presented with weight loss, night pain which was deep an intense and a mass on the dorsum of the foot, seen in B below. In this particular case, a referral to a surgeon or sarcoma service should be done. However, Mr. Welck underlines that this presentation should not be mistaken with a ganglion (A).
- Fast onset of pain
- Not painful
- Soft lump, fluctuating in size
- Slow insidious onset of pain
- Pain at night
- Hard lump, slowly growing
t was an honour to have Mr. Welck to our Studio and we look forward to welcoming him back again soon. Images were kindly reproduced from Mr. Welck’s presentation.
– Carlotta Pietroboni Pini BSc, Physiotherapist
Hutchison, A.M., Topliss, C., Beard, D., Evans, R.M. & Williams, P. 2015, “The treatment of a rupture of the Achilles tendon using a dedicated management programme”, The bone & joint journal, vol. 97-B, no. 4, pp. 510.