Ankle and foot pathologies

Question 1

anatomical classification potts fracture- anatomical

Answer 1

Isolated medial malleolus
isolated lateral malleolus (most common)
Bimalleolar fx
trimalleolar fx

Question 2

Danis and Weber classification A

Answer 2

distal fibula below syndesmosis

Stable conservative treatment

Question 3

DW class B

Answer 3

distal fibula at level of syndesmosis

Treated conservatively if stable, if not do fixation

Question 4

DW class C

Answer 4

fibula fracture above level of syndesmosis

usually unstable requires surgical fixation

Question 5

Lauge Hansen classification- supination adduction

Answer 5

1. distal fibula transverse fracture
2. Medial malleolus vertical fracture

Question 6

LH class- supination external rotation

Answer 6

60%
1. ant tib fib ligament
2. distal fib oblique spiral fx
3. post tib fib lig or posterior mallelous alvusion
4. medial malleolus fx or deltoid lig

Question 7

LH class- pronation external rotation

Answer 7

1. medial malleolus fx or deltoid lig
2. ant tib fib lig
3. fibula proximal to plafond - oblique spiral fx
4. post tib fib lig or posterior malleolus avulsion

Question 8

LH class- pronation abduction

Answer 8

1. medial malleolus fx
2. ant tib fib lig
3. fibula proximal to plafond- transverse or comminuted

Question 9

etiology of plafond fx

Answer 9

talus drilling upward into the tibial plafond
High energy - MVA , fall from height
Low energy -ski injury most common (impact with rotation of tibia)

Question 10

management of plafond fx

Answer 10

Advanced life support and stabilization

Not displaced well aligned -cast immobilization and nonweightbearing

displaced -surgical 4 stage approach

Question 11

displaced surgical approach for plafond fracture

Answer 11

Restore fibula length and reestablish lateral column

Restore articular surface of distal tibia

Autologous bone graph to fill metaphyseal bone defects

Buttress plate placed on distal aspect of tibia

Question 12

maisonneuve fx

Answer 12

unstable fracture caused by pronation, external rotation ankle injury

Proximal fibula fracture and deltoid ligament injury
May include medium malleolus fx and syndesmotic injury

Require surgical fixation of the fibula

Question 13

bosworth fx dislocation

Answer 13

fibula is dislocated posteriorly at the ankle

Posterior tibial border block fibular reduction

Surgery to reduce, reposition the fibula and incisura fibularis

Question 14

frank (clear) calcaneal fx

Answer 14

mechanism- fall or jump from height, MVA

managed with immobilization or surgical fixation if displaced

Question 15

calcaneal stress fx

Answer 15

recent new activity or a change in that activity

Repetitive load and stress like runners or military recruits

May not show on plain film x-ray requires a bone scan or MRI

manage- produce pain, manage load, gradual progression to full weight-bearing and activity

Question 16

Chopart fx dislocation

Answer 16

dislocation of the mid tarsal joints with associated fractures of the calcaneus, cuboid and navicular bones

Less common

Question 17

Chopart fx management

Answer 17

ORIF or displaced malaligned fracture or dislocation
Closed reduction, rigid cast 6 to 8 weeks with PWB
Focus on maintenance of arch

Question 18

chopart fx symptoms

Answer 18

abnormal position of forefoot mediately directed
Swelling in dorsum of foot
midfoot pain

Question 19

lisfranc fx

Answer 19

fracture in mid foot, TMT joint region

Severity ranges from mild to severe
Ligaments are often torn, in lieu of fractures, or in combination
Fracture dislocations occur
Cartilage damage can occur can lead to osteo arthritis

Often a low energy twist and fall injury or someone landing on foot

Question 20

lisfranc fx symptoms

Answer 20

dorsal foot swelling, and bruising
Bruising on the bottom of the foot is highly suggestive of this fracture
Pain in mid foot with standing walking and pushoff
Weight-bearing may not be possible due to pain

Question 21

lisfranc fx management

Answer 21

depends on severity

Non-fractured non-dislocated - nonweightbearing boot for six weeks progress to weight-bearing in boot

fractured dislocated - surgical fixation and realignment via ORIF or mid foot fusion

Postop nonweightbearing for 6 to 8 weeks
Manage weight-bearing progression and work on impairments

Question 22

metatarsal fx

Answer 22

61% of all foot fractures in children
41% of those in the fifth metatarsal

Direct trauma or held in place while body falls over the area
Stress fractures due to repetitive loading or activity -March fracture

Question 23

fifth metatarsal fracture; Lawrence and botte

Answer 23

proximal fractures

Zone 1- tuberosity
zone 2- metaphysis/diaphysis junction
Zone 3- diaphyseal within 1.5 cm of tuberosity

Question 24

Avulsion fracture of fifth metatarsal

Answer 24

zone 1- pseudo Jones fracture

Mechanism is typically inversion plantar flexion

Question 25

Jones fractured fifth metatarsal

Answer 25

Zone 2- proximal fifth metatarsal fracture Mechanism- plantar flexion with forceful adduction of forefoot Poor healing ; nonunion rates 15 to 30%

Question 26

stress fracture of fifth metatarsal

Answer 26

Zone 3 Chronic repetitive micro trauma Pain with activities over months Increased risk of nonunion

Question 27

dancers fracture fifth metatarsal

Answer 27

Mid shaft fracture Mechanism - rolling foot and Demi point position or while landing a jump

Question 28

phalangeal Fracture

Answer 28

common Symptoms include swollen, discolored, painful, sometimes deformed management Pain control, protected weight-bearing initially Buddy taping; wide toed shoes for comfort walking normally within two weeks Fully healed within 6 to 8 weeks

Question 29

initial immobilization phase for patients with fractures

Answer 29

Assistive device training Patient education Monitor for vascular soft tissue other complications Exercise uninvolved areas infrequent visits

Question 30

post immobilization phase for patients with fractures

Answer 30

Protect healing tissues Pain control Manual therapy exercise HEP Progress towards return to activity

Question 31

medial tibial stress syndrome

Answer 31

Accounts for inflammation traction event on the tibial aspect of the leg common in runners Most accurately named medial tibial traction periostitis, or medial tibial periostitis Tightness tenderness, throbbing along, tibial crest that comes with activity and settles with rest

Question 32

Causes of medial tibial stress syndrome

Answer 32

inappropriate footwear Muscle weakness Poor running mechanics Improper training Tight gastrocsoleus Hyper mobile pronated feet Excessive supination

Question 33

tibialis anterior tendinopathy

Answer 33

will look very similar to MTSS MMT testing should provoke palpation key be sure to screen the lumbar Gate and running analysis key

Question 34

Tibialis posterior tendinopathy

Answer 34

pf, inv, and anti pronator muscle Pain with AROM and or MMT repetitive stress pes planus, hyper mobile feet Irritation at insertion on navicular, or the medial malleoli Look at resting and dynamic foot posture

Question 35

peroneal tendonopathy

Answer 35

occurs in sulcus behind lateral malleoli or at cuboid Overuse or friction Often after inversion sprain Can rupture at retinaculum leading to peroneal subluxation

Question 36

tarsal tunnel syndrome

Answer 36

Posterior tibial neuritis Lesion to posterior tibial nerve in flexor retinaculum Entrapment or traction behind medial malleoli Running on hard surfaces or poor fitting shoes Overpronation

Question 37

tarsal tunnel syndrome examination

Answer 37

swelling Medial ankle and heel pain Positive sensory loss to medial knee Positive tinels sign Possible adverse neural tension

Question 38

Chronic exertional compartment syndrome

Answer 38

typically anterior two year history prior to diagnosis runners and soccer players Muscle herniation can be palpated in 40 to 60% of patients Neurologic weakness and numbness in respective compartment

Question 39

Chronic exertional compartment syndrome examination

Answer 39

pain comes at predictable periods Tested with wick catheter before and after treadmill test burning, numb, tingling, pain, pressure, pallor, pulse Consider transition to forefoot running

Question 40

keys to treating shin pain

Answer 40

Rice Flexibility program for GS complex Retrain inhibited musculature Restore CKC dorsiflexion Strengthen inhibited musculature Improve intrinsic foot strength Short term use of low dye taping Running evaluation and retraining Address associated triggerpoints footwear changes if necessary

Question 41

achilles Tendinitis

Answer 41

inflammation of achilles tendon Overuse overloaded state Gradual onset Decreased flexibility exacerbates

Question 42

achilles tendonosis

Answer 42

chronic Hypovascular zone 2 to 6 cm from insertion May present with crepitus Often lack of CKC DF thickening of Achilles tendon Tight painful gastrocsoleus with TPs painful resisted plantar flexion Anti-inflammatories don’t work

Question 43

achilles tendonosis treatment

Answer 43

IASTM Stretching No NSAIDs Eccentric training 3 sets of 15 eccentric heel drops 2 times daily for 12 weeks

Question 44

achilles tendon rupture

Answer 44

Chronic degeneration due to inflammation Forceful, sudden contraction Audible pop Cortizone injection is a risk factor 30 to 40-year-old male

Question 45

achille tendon rupture symptoms and examination

Answer 45

palpable or visible defect in tendon Gate changes unable to push off swelling and ecchymosis Positive thompson test most Treated surgically

Question 46

halux abductovalgus

Answer 46

medial deviation of first metatarsal head in relation to center of the body Adolescent - may require surgical intervention often associate with hyper pronation of the rear foot Degenerative - degeneration of the first metatarsal head and base of proximal phalanx

Question 47

hallux abductovalgus interventions

Answer 47

strengthen intrinsic muscles Manual therapy of foot and ankle Modify footwear Custom orthotics Splinting

Question 48

mortons neuroma

Answer 48

Pain and paresthesia in interdigital space with fibrous entrapment of interdigital nerve Conservative manage- decompression, change foot wear modification, metatarsal pads, mobilization Surgical if symptoms do not improve