The Os Trigonum Syndrome: Difference between revisions

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== Physical Therapy Management <br> ==
== Physical Therapy Management <br> ==


Rest, ice, massage and ultrasound treatment will reduce inflammation.  
Rest, ice, massage and ultrasound treatment will reduce inflammation.<ref name="1" /><ref name="2" /><ref name="8" />


Isometric and eccentric exercises to strengthen and stretch the lower-leg muscles are used in a physiotherapeutic treatment.  
Isometric and eccentric exercises to strengthen and stretch the lower-leg muscles are used in a physiotherapeutic treatment.<ref name="9" />


Also exercises to improve deep muscle action during plantarflexion are designated. The deep muscles of the lower leg, such as tibialis posterior, flexor digitorum longus, flexor hallucis longus and the peroneals are the opposites of the M.gastrocnemius. By using the deep muscles, the talus is shifted forward during plantarflexion, what will reduce the impact of the os trigonum on the posterior tibia, contrary to using the M.gastrocnemius, which results in lifting the calcaneus and compression of the os trigonum.  
Also exercises to improve deep muscle action during plantarflexion are designated. The deep muscles of the lower leg, such as tibialis posterior, flexor digitorum longus, flexor hallucis longus and the peroneals are the opposites of the M.gastrocnemius. By using the deep muscles, the talus is shifted forward during plantarflexion, what will reduce the impact of the os trigonum on the posterior tibia, contrary to using the M.gastrocnemius, which results in lifting the calcaneus and compression of the os trigonum.<ref name="9" />


<u>[[Image:Os trigonum 5.png|left|800x216px]]</u>  
<u>[[Image:Os trigonum 5.png|left|800x216px]]</u>  


<u>Fig. 5</u>: Strengthening of the deep muscles. Performing demipointe (2) and en pointe (3) while holding the calcaneus in place with the hands. Knee flexion at 90° to prevent contraction of the M.gastrocnemius.  
<u>Fig. 5</u>: Strengthening of the deep muscles. Performing demipointe (2) and en pointe (3) while holding the calcaneus in place with the hands. Knee flexion at 90° to prevent contraction of the M.gastrocnemius.<ref name="9" />


<br>
<br>


Also proprioceptive exercises on a tilt board are applied to correct malalignments of the lower limb.<br>All of these exercises were found in only one study of 11 dancers with a posterior ankle impingement including 6 cases with an os trigonum. Nine of them had good results with these exercises, the other two ones underwent surgical excision.  
Also proprioceptive exercises on a tilt board are applied to correct malalignments of the lower limb.<ref name="9" /><br>All of these exercises were found in only one study of 11 dancers with a posterior ankle impingement including 6 cases with an os trigonum. Nine of them had good results with these exercises, the other two ones underwent surgical excision.<ref name="9" />


== References  ==
== References  ==

Revision as of 00:16, 20 March 2012

Welcome to Vrije Universiteit Brussel's Evidence-based Practice project. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Gaelle De Coster

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Search Strategy[edit | edit source]

Search Engines: Pubmed, Web of knowledge
                           Google Scholar and Google books are also practical.

Key Words: os trigonum syndrome (AND treatment NOT surgery, AND physical therapy), posterior ankle impingement, ballet dancers

Definition/Description[edit | edit source]

The Os Trigonum Syndrome refers to pain posterior of the ankle and reduced plantarflexion caused by “the nutcracker-phenomenon”. When an os trigonum is present, this accessory ossicle together with surrounding soft tissues can become wedged between the tibia, talus and calcaneus. This can lead to inflammation of the involved structures. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The os trigonum syndrome can also be named the symptomatic os trigonum, the talar compression syndrome or posterior tibial talar impingement syndrome.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title


Os trigonum 1.png

Fig. 1: Sagittal T1-weighted MR image in plantar flexion showing the “nutcracker-phenomenon”. The os trigonum together with
surrounding soft tissues are wedged between talus, calcaneus and tibiaCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title









Clinically Relevant Anatomy[edit | edit source]

 Embryologically, the body of the talus and the posterior talar process are separate ossification centers. Between the 7th and the 13th year of life, the posterior talar process appears as a separate ossicle: the os trigonum. Normally, within a year of its appearance, it fuses with the talus, but about 7% of the adult population has still this os trigonum. It can be present unilaterally or bilaterally, with smooth or serrated margins. The os trigonum is usually seen as an individual bone, but can also exist of two or more pieces. It is less than 1cm in size, but this can vary. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The os trigonum is usually triangular with an anterior, inferior and posterior surface. The anterior surface connects with the lateral tubercle by cartilaginous synchondrosis. The inferior side may articulate with the calcaneus. The posterior surface is nonarticular, but is used as a point of attachment for capsuloligamentous structures. The os trigonum may also be round or oval. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The flexor hallucis longus tendon is situated medial to the os trigonum, in the sulcus between the medial and lateral tubercle.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
 

Epidemiology /Etiology[edit | edit source]

There are three mechanisms for the development of an os trigonum:
1.fusion failure of an ossification center
2.fracture of the posterior margin of the tibia
3.fracture of the posterior process of the talus.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The presence of an os trigonum isn’t sufficient to create the syndrome. It must be combined with a traumatic event. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The os trigonum syndrome can be caused by overuse or trauma. When it’s due to overuse, it’s mostly found by ballet dancers and runners. The forceful plantar flexion that happens during an “en pointe” or “demi-pointe” position, as well as by running downhill, produces compression on the posterior aspect of the ankle joint. In cause of a trauma, the os trigonum can be displaced by forced plantarflexion. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Soft tissue structures, including the ankle joint capsule and surrounding ligaments, may react by forming a hypertrophic mass. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Characteristics/Clinical Presentation[edit | edit source]

A load-dependent, persistent pain between the Achilles tendon and the peroneal tendons is the first indicator of the syndrome. Stiffness, weakness and swelling can also be observed in this zone. The second main symptom is a decrease in plantarflexion compared with the unaffected ankle. In some cases the bony prominence may be palpable.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Eversion or inversion movements may cause discomfort. Pain at the posterior aspect of the ankle will be experienced by plantarflexion of the foot or dorsiflexion of the great toe.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Differential Diagnosis[edit | edit source]

The following diagnosis must be considered:

• Tendinitis flexor hallucis longusCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title;
• Tarsal tunnel syndromeCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title;
• Subtalar pathologyCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title;
• Achilles tendinopathyCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title;
• Peroneal tendinopathyCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title;
• Achilles tendon bursitisCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title;
• Osteochondritis dissecans of the talus. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Diagnostic Procedures[edit | edit source]

MEDICAL

- Lateral X-rayCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, possibly weight-bearing, with the foot in full plantarflexion.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
- CT-scanCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
- MRI is the preferable techniqueCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title for establishing the presenceCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title and the size of the ossicleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, coexisting pathologiesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title and soft tissue and bone damage.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Flexion/extension MRI gives information about the mobility of the os trigonum.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
- Technetium bone scanCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title shows increased uptake in the region of the os trigonum.

Os trigonum 4.png
Os trigonum 3.png

 

Fig. 3: lateral x-ray of foot showing os trigonumCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Fig. 4: Technetium bone scanCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title










Examination [edit | edit source]

On posterolateral palpation, between the Achilles tendon and peroneal tendons, pain and swelling may be noticed.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The passive forced plantarflexion test: It should be executed with repetitive quick and passive hyperplantarflexion movements in a neutral position, possibly with exo- or endorotation movement on the point of maximal plantarflexion. Thereby grinds the ossicle between tibia and calcaneus.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Medical Management
[edit | edit source]

Nonsteroidal anti-inflammatory medication or corticosteroid injections are used to reduce soft tissue inflammation.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
In case of fracture, a below-knee cast is used for 4-6weeks.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

If symptoms persist, surgery is applied. (high evidence, all studies mention good results.)
This involves the removal of the os trigonum. Postoperatively we apply a plaster cast for 5days. Hereafter physiotherapy is started for 4-8 weeks. Afterwards full sports activities can be resumed. It will take up to 6 months until full recovery.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Physical Therapy Management
[edit | edit source]

Rest, ice, massage and ultrasound treatment will reduce inflammation.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Isometric and eccentric exercises to strengthen and stretch the lower-leg muscles are used in a physiotherapeutic treatment.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Also exercises to improve deep muscle action during plantarflexion are designated. The deep muscles of the lower leg, such as tibialis posterior, flexor digitorum longus, flexor hallucis longus and the peroneals are the opposites of the M.gastrocnemius. By using the deep muscles, the talus is shifted forward during plantarflexion, what will reduce the impact of the os trigonum on the posterior tibia, contrary to using the M.gastrocnemius, which results in lifting the calcaneus and compression of the os trigonum.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Os trigonum 5.png

Fig. 5: Strengthening of the deep muscles. Performing demipointe (2) and en pointe (3) while holding the calcaneus in place with the hands. Knee flexion at 90° to prevent contraction of the M.gastrocnemius.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title


Also proprioceptive exercises on a tilt board are applied to correct malalignments of the lower limb.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
All of these exercises were found in only one study of 11 dancers with a posterior ankle impingement including 6 cases with an os trigonum. Nine of them had good results with these exercises, the other two ones underwent surgical excision.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

References[edit | edit source]

see adding references tutorial.