7- Ankle & Foot Flashcards
What muscle is associated with a fracture of the 1s & 5th metatarsal bone?
Peroneus longus (inserts onto 1st MT).
Peroneus brevis (inserts onto 5th MT).
List 3 Common causes of in-toeing in children 🔑🔑 Dr. Haitham ALC Clinic
- Femoral anteversion
- Internal tibial torsion
- Metatarsus adductus
- Habit
Mention the structures inside the Flexor Retinaculum 🔑🔑
Lateral Ankle Sprain.🔑🔑
Types
Common Injuries associated / complications
Management
LATERAL ANKLE SPRAIN
Mechanism
- Inversion of a plantar-flexed foot
- History of “rolling over” the ankle
- ATFL most commonly injured
Types
- High ankle sprain 10%: syndesmosis injury
- Low ankle sprain 90%: ATFL and CFL injury
Examination
- Swelling, Ecchymosis, Tenderness
- Anterior drawer test >5 mm
- Talar tilt test >5-10 degrees >30 all three lateral ligaments are ruptured
Complications
- Injuries to the syndesmosis
- Peroneal tendinopathy
- Sinus tarsi
ER - POLICE - 2MS
Grade 1 (Partial ATFL) & Grade 2 (Comp ATFL, Partial CFL)
- Education: Rest
- Protection & Orthosis: immobilization, taping, and bracing
- Loading: ROM, strengthening, proprioceptive exercises
- Ice, compression, elevation
- Modalities: Moist heat, warm whirlpool, contrast baths, US
- Medications: NSAIDs, analgesics
Grade 3 (Comp ATFL & CFL)
- Six-month trial of rehabilitation and bracing
- High-performance athlete with critical instability → surgical reconstruction of torn ligaments 3 months post injury
- Ligament repair, tenodesis
Cuccurollo 4th Edition Chapter 4 MSK pg255-257 & pg263
Patient presented with lateral ankle pain. Hx previous ankle sprain. 🔑
PERONEAL TENDINOPATHY
Causes
- Tenosynovitis or rupture (Repetitive forceful eversion)
- Ankle subluxation or dislocation (Skiing injury)
Examination
- Pain and weakness with resisted dorsiflexion and eversion
- Weakness with the inability to actively evert the foot
- US may help visualize peroneal tendon subluxation over the lateral malleolus
Treatment
- Tenosynovitis: Same treatment as for a lateral ankle sprain “ER - POLICE - 2MS”
- Rupture/subluxation/dislocation:
- Orthopedic evaluation
- 4 to 6 weeks of immobilization in a plantar-flexed position
Cuccurollo 4th Edition Chapter 4 MSK pg255-257 & pg263
Patient presented with lateral ankle pain pointed with finger. Hx previous ankle sprain. 🔑
SINUS TARSI SYNDROME
Mechanism
- Talocalcaneal ligament sprain
Predisposing Factors:
- Ankle instability
- History of prior ankle injury
- Excessive foot pronation causing adduction of the talus
- History of arthritis: RA, gout, and seronegative spondyloarthropathies
Treatment
- Corticosteroid injection
- Decompression of the tunnel contents
Cuccurollo 4th Edition Chapter 4 MSK pg255-257 & pg263
List 4 DDx for medial ankle pain 🔑🔑
- Medial Ankle Sprain (Deltoid Ligament Sprain)
- Tarsal Tunnel Syndrom (Tibial Nerve Injury)
- Tibialis Posterior Tendinopathy
- Tibialis Anterior Tendinopathy
Foot strikes the ground instead of the ball in soccer or an extra point in football. Diagnosis, 3 Complications, Test, Management In case of no trauma, what is the most likely diagnosis for medial ankle pain?
DELTOID LIGAMENT SPRAIN
Mechanism of Injury
- Foot strikes the ground instead of the ball in soccer or an extra point in football.
- Pure eversion is rare (Medial ankle ligaments are stronger than lateral ankle ligaments)
Grading Scale
Grade 1: Stretch
Grade 2: Stretch partial tear
Grade 3: Full tear
Examination
- Medial foot swelling and ecchymosis
- Pain on eversion
- Negative anterior drawer test
- Positive eversion test
Imaging
- X-rays with AP, lateral, and oblique views
- MRI if indicated
Treatment
- Same as lateral ankle injuries
- Immobilization for 4 to 6 weeks
- Molded shoe orthosis for 4 to 6 months
- Surgery if conservative measures fail
Complication
- Syndesmosis ankle injury and Maisonneuve fractures
Cuccurollo 4th Edition Chapter 4 MSK pg263
Patient with medial foot pain after planterflexion. Hx ankle sprain.
TIBIALIS POSTERIOR TENDINOPATHY
Anatomy
- Origin: Interosseous membrane and the posterior surface of the tibia and fibula
- Insertion: Tuberosity of the navicular, cuboid, and base of the second to fourth metatarsals
Function
- Plantar flexes the ankle and inverts the foot
- Maintains the medial longitudinal arch
Mechanism
- Tenosynovitis or tendon rupture (Repetitive forceful inversion)
Examination
- “too many toes” in case of rupture
- Weakness with inversion and plantar flexion
Treatment
- Acute: Same as lateral ankle sprains
- Conservative: Rehabilitation, orthotics to address pronation
- Surgical: Tendon transfer, excising the accessory navicular
Cuccurollo 4th Edition Chapter 4 MSK pg263
Hx of ankle sprain, Pain and swelling on the anterior aspect just above the ankle.
TIBIOFIBULR SYNDESMOSIS INJURY
Function
- Maintain the integrity of the ankle mortise.
- Resist forces that attempt to separate the tibia and fibula
Mechanism
- Hyperdorsiflexion and forceful eversion of the ankle
- Direct blow to the foot with the ankle held in external rotation
Presentation
- High ankle sprain
- Pain and swelling on the anterior aspect just above the ankle
Imaging
- Mortise view: widening between the distal tibia and fibula
- Proximal fibula fracture (Maisonneuve fracture)
Examination
- Squeeze test: compression of the distal tibia and fibula proximal to the injury
- Stress test: externally rotate the foot, knee held at 90 degrees.
Treatment
- Surgical: Screw fixation to stabilize the ankle mortise
Cuccurollo 4th Edition Chapter 4 MSK pg263
Predisposing factors for tibialis posterior tendinopathy. 🔑🔑
- Broad pelvis
- Increased femoral anteversion
- Squinting patellae or genu valgum
- Increase Q angle
- Excess pronation of the foot.
Sudden push-off with the foot in the extension position (e.g., landing from a jump) Diagnosis of Heel Pain, Predisposing Factor, Test, Management
💡 Sudden push-off with the foot in the extension position (e.g., landing from a jump)
Achilles tendonitis
- Repetitive eccentric overload causing inflammation and microtears of the tendon
Achilles tendon rupture
- Inflammatory: Inflammation and degeneration causing a series of microtears
- Vascular: Inadequate vascularization 2 to 6 cm proximal to the insertion of the tendon
Predisposing Factors
- Training errors (Body - Equipment - Program)
- Sharp increase in mileage or intensity
- Change in recent footwear
- Anatomic causes
- Tight hamstrings and Achilles tendons
- Pes cavus
- Genu varum
- Hyperpronation.
- Increased age leads to an inflexibility of the tendon and decreased tensile strength
Examination
- Tendonitis
- Posterior ankle pain, swelling
- Pain elicited on push-off
- Achilles tendon rupture “any muscle rupture”
- Sudden audible snap with immediate swelling, ecchymosis
- Weakness in plantar flexion
- Positive Thompson’s test
Imaging
- US may be helpful in differentiating partial from complete tear.
ER - POLICE - MS
Achilles Tendonitis
- EDUCATION: Relative rest
- PROTECTION: Short-term immobilization (splinting or bracing) for 2 weeks then might benefit from heel lifts
- LOADING: Stretching and strengthening (eccentric strength exercises)
- MEDICATION: Do not inject corticosteroids into the Achilles tendon → risk of rupture
Achilles tendon rupture
- EDUCATION: Complete rest
- PROTECTION
- Nonweight bearing with crutches
- CAM boot for 8-12 weeks → Increase dorsiflexion
- LOADING: Stretching and strengthening start at 2 weeks
- SURGERY:
- Tendon repair for active individuals
- Flexion dial lock brace for 2 to 6 weeks
Cuccurollo 4th Edition Chapter 4 MSK pg260-261
List 5 DDx for heel pain 🔑🔑
- Achilles Tendonitis
- Retrocalcaneal bursitis
- Haglund deformity: Retrocalcaneal exostosis
- Sever’s disease: Calcaneal apophysitis
- Planter Fasciitis
- Calcaneal fracture
- Tibial Neuropathy
- Fat pad contusions or atrophy
- S1 Radiculopathy
PMR Secrets 3rd Edition Chapter 48 Foot & Ankle pg392
List 3 DDx for Retrocalcaneal pain, Predisposing Factor
DDx for Retrocalcaneal pain
- Retrocalcaneal bursitis
- Achilles tendinitis/tendinopathy
- Sever’s disease: Calcaneal apophysitis (young athletes)
- Haglund syndrome:
- Retrocalcaneal bursitis
- Achilles tendinitis/tendinopathy
- Haglund’s deformity: Retrocalcaneal exostosis (enlargement of the posterosuperior tuberosity)
Predisposing Factor
- High heels or shoes
- Hard heel counter
Examination
- Tenderness and swelling
Treatment
- Change or alter footwear
- Surgical excision of the bursae
Cuccurollo 4th Edition Chapter 4 MSK pg262
Chronic ankle pain, Weak dorsiflexion. Diagnosis, Anatomy, Gait abnormality & Management.
TIBIALIS ANTERIOR TENDINOPATHY
Insertion
- Medial aspect of the base of the first metatarsal and the first cuneiform bones
Mechanism of Injury
- Tenosynovitis → Inflammation
- Tendon rupture → Degenerative process or eccentric overload
Presentation
- Painless foot slap
- Chronic ankle pain
- Increased tenderness and weakness with active dorsiflexion and passive plantar flexion
- Palpable defect
Treatment
- Conservative versus surgical, depending on the patient’s age and functional needs
Cuccurollo 4th Edition Chapter 4 MSK pg264
You are reviewing a patient immediately after twisting injury to his left ankle. He was complaining of significant pain in his ankle. What are the indications for obtaining radiographic series for this patient?🔑🔑 EXAM 🟦
OTTAWA ANKLE RULES
Ankle X-Ray
- Bone tenderness at the posterior edge (6cm) or tip of the medial malleolus
- Bone tenderness at the posterior edge (6cm) or tip of the lateral malleolus
- Inability to WB immediately and in ER for four steps
Foot X-Ray
- Bone tenderness at the navicular bone
- Bone tenderness at the base of 5th metatarsal
- Inability to WB immediately and in ER for four steps
Planter fasciitis, mechanism, risk factors 🔑, management
What is the gold standard method of diagnosing plantar fasciitis? 🔑
Increased tension on the plantar fascia leads to chronic inflammation
- Pes cavus (high arch)
- Pes planus (flat foot)
- Obesity
- Tight Achilles tendon
- Heel spurs may contribute to the etiology (50% to 75%)
Examination
- Tenderness is observed over the medial aspect of the heel
- Pain can be elicited by hyperextension of the great toe
- Pain is worse in the morning or at the start of weight-bearing activities
Imaging
- Plain films to assess for bony spur
- Ultrasound. Measure thickness of fascia. (gold standard)
Risk Factors
- Tight Achilles tendon
- Pes planus (flat foot)
- Obesity
Protection & Orthosis
- Shoe modifications (heel pads, cushion, and lift)
- Nighttime dorsiflexion splints
Loading
- Achilles tendon and plantar fascia stretching (eccentric calf and fascia +/- ball)
ICE & Modalities
- ICE 15 minutes 4-6 times daily
- ESWT
Medications
- NSAIDs
- Injections: Do not inject anesthetic/corticosteroid into the subcutaneous tissue or fascial layer. Stay out of the superficial fat pad to avoid fat necrosis
Surgery
- Surgical: Plantar fascia release (rarely indicated)
Cuccurollo 4th Edition Chapter 4 MSK pg266
List 5 etiologies of pes planus.
- Charcot foot.
- Marfans.
- Traumatic – eg Lis franc dislocation
- Tib post dysfunction or rupture.
- Inflammatory arthropathies – eg RA.
- Plantar fascia rupture
- Spring ligament dysfunction (plantar calcaneonavicular ligament).
Ref: Wheeless, orthobullets.
Pain in the web spaces between the metatarsal heads. Diagnosis & 4 Shoe Modification 🔑🔑
MORTON’S NEUROMA
Mechanism
- Perineural fibrosis of the interdigital nerves
Examination
- Sharp shooting forefoot pain radiating to the affected digits
- Dysesthesias and numbness
- Apply direct pressure to the interdigit web space with one hand and then apply lateral and medial foot compression to squeeze the metatarsal heads together
Shoe Modification
- Wide toe box
- Adequate insole cushioning
- Metatarsal pads (aka neuroma pads)
- Low heel height
Treatment
- Corticosteroid injection
- Excision if indicated
Cuccurollo 4th Edition Chapter 4 MSK pg266-267
Diagnosis, Examination, 2 Shoe Modifications.
HALLUX DISORDERS
MTP sprain / Turf Toe
- Acute injury to the ligaments and capsule of the first MTP joint
- Chronic sprains may lead to hallux rigidus (hallux OA)
- Acute onset of pain, tenderness, and swelling of the MTP joint,
- Pain on passive dorsiflexion
- Firmer toe box shoes
- Taping
- Immobilization by first metatarsal splints
- Use of orthoplast inserts
Hallux valgus
- Lateral deviation of the first toe > 15 degrees between tarsus and metatarsus
Hallux rigidus
- Degenerative joint disease of the first MTP joint leading to pain and stiffness
- Affects female >> males
- Decreased ROM of the MTP joint
- Antalgic gait pattern.
- Surgical debridement
Shoe
- High toe box
- Forefoot rocker bottom
Cuccurollo 4th Edition Chapter 4 MSK pg267-268
Answer 🔑🔑
1. HAMMER TOE
- Flexion of the PIP joint
- Passive extension of MTP joint
- DIP joint is usually not affected.
Mechanism
- Tight shoe wear that crowds the toes
- After trauma
Treatment
- Shoes with high toe boxes
- Home passive manual stretching
2. CLAW TOE
- Extension of MTP
- Flexion of the PIP
- Flexion of the DIP
Mechanism
- Incompetence of the foot intrinsic muscles
- Neurologic disorders affecting the strength of these muscles
Causes → Polyneuropathy “Champagne legs”
- Diabetes
- Alcoholism
- Peripheral neuropathies
- Charcot–Marie– Tooth disease
- Spinal cord tumors
Treatment
- Soft insoles
- High toe boxes
- Splints
- Surgical correction may be necessary if conservative treatment
3. MALLET TOE
- Flexion deformity of DIP joint
- Normal alignment of PIP and MTP joints
Mechanism
- Jamming type injury
- Wearing tight shoes
Treatment
- Shoes with soft insoles and high toe boxes
Cuccurollo 4th Edition Chapter 4 MSK pg268-269
Tenderness along the tendon at the posteromedial aspect of the great toe. Diagnosis, Origin & Insertion. 🔑🔑
Flexus Hallucis Longus (FHL) Injury
- Dancer’s tendonitis → Repetitive push-off maneuvers
- Origin: Distal fibula and interosseous membrane
- Insertion: Base of the distal phalanx of the great toe
Cuccurollo 4th Edition Chapter 4 MSK pg260-261
