Ankle and foot pathologies Flashcards
anatomical classification potts fracture- anatomical
Isolated medial malleolus
isolated lateral malleolus (most common)
Bimalleolar fx
trimalleolar fx
Danis and Weber classification A
distal fibula below syndesmosis
Stable conservative treatment
DW class B
distal fibula at level of syndesmosis
Treated conservatively if stable, if not do fixation
DW class C
fibula fracture above level of syndesmosis
usually unstable requires surgical fixation
Lauge Hansen classification- supination adduction
- distal fibula transverse fracture
- Medial malleolus vertical fracture
LH class- supination external rotation
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
LH class- pronation external rotation
- medial malleolus fx or deltoid lig
- ant tib fib lig
- fibula proximal to plafond - oblique spiral fx
- post tib fib lig or posterior malleolus avulsion
LH class- pronation abduction
- medial malleolus fx
- ant tib fib lig
- fibula proximal to plafond- transverse or comminuted
etiology of plafond fx
talus drilling upward into the tibial plafond
High energy - MVA , fall from height
Low energy -ski injury most common (impact with rotation of tibia)
management of plafond fx
Advanced life support and stabilization
Not displaced well aligned -cast immobilization and nonweightbearing
displaced -surgical 4 stage approach
displaced surgical approach for plafond fracture
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
maisonneuve fx
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
bosworth fx dislocation
fibula is dislocated posteriorly at the ankle
Posterior tibial border block fibular reduction
Surgery to reduce, reposition the fibula and incisura fibularis
frank (clear) calcaneal fx
mechanism- fall or jump from height, MVA
managed with immobilization or surgical fixation if displaced
calcaneal stress fx
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
Chopart fx dislocation
dislocation of the mid tarsal joints with associated fractures of the calcaneus, cuboid and navicular bones
Less common
Chopart fx management
ORIF or displaced malaligned fracture or dislocation
Closed reduction, rigid cast 6 to 8 weeks with PWB
Focus on maintenance of arch
chopart fx symptoms
abnormal position of forefoot mediately directed
Swelling in dorsum of foot
midfoot pain
lisfranc fx
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
lisfranc fx symptoms
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
lisfranc fx management
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
metatarsal fx
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
fifth metatarsal fracture; Lawrence and botte
proximal fractures
Zone 1- tuberosity
zone 2- metaphysis/diaphysis junction
Zone 3- diaphyseal within 1.5 cm of tuberosity
Avulsion fracture of fifth metatarsal
zone 1- pseudo Jones fracture
Mechanism is typically inversion plantar flexion
Jones fractured fifth metatarsal
Zone 2- proximal fifth metatarsal fracture
Mechanism- plantar flexion with forceful adduction of forefoot
Poor healing ; nonunion rates 15 to 30%
stress fracture of fifth metatarsal
Zone 3
Chronic repetitive micro trauma
Pain with activities over months
Increased risk of nonunion
dancers fracture fifth metatarsal
Mid shaft fracture
Mechanism - rolling foot and Demi point position or while landing a jump
phalangeal Fracture
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
initial immobilization phase for patients with fractures
Assistive device training
Patient education
Monitor for vascular soft tissue other complications
Exercise uninvolved areas
infrequent visits
post immobilization phase for patients with fractures
Protect healing tissues
Pain control
Manual therapy exercise HEP
Progress towards return to activity
medial tibial stress syndrome
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
Causes of medial tibial stress syndrome
inappropriate footwear
Muscle weakness
Poor running mechanics
Improper training
Tight gastrocsoleus
Hyper mobile pronated feet
Excessive supination
tibialis anterior tendinopathy
will look very similar to MTSS
MMT testing should provoke
palpation key
be sure to screen the lumbar
Gate and running analysis key
Tibialis posterior tendinopathy
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
peroneal tendonopathy
occurs in sulcus behind lateral malleoli or at cuboid
Overuse or friction
Often after inversion sprain
Can rupture at retinaculum leading to peroneal subluxation
tarsal tunnel syndrome
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
tarsal tunnel syndrome examination
swelling
Medial ankle and heel pain
Positive sensory loss to medial knee
Positive tinels sign
Possible adverse neural tension
Chronic exertional compartment syndrome
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
Chronic exertional compartment syndrome examination
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
keys to treating shin pain
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
achilles Tendinitis
inflammation of achilles tendon
Overuse overloaded state
Gradual onset
Decreased flexibility exacerbates
achilles tendonosis
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
achilles tendonosis treatment
IASTM
Stretching
No NSAIDs
Eccentric training
3 sets of 15 eccentric heel drops
2 times daily for 12 weeks
achilles tendon rupture
Chronic degeneration due to inflammation
Forceful, sudden contraction
Audible pop
Cortizone injection is a risk factor
30 to 40-year-old male
achille tendon rupture symptoms and examination
palpable or visible defect in tendon
Gate changes unable to push off
swelling and ecchymosis
Positive thompson test
most Treated surgically
halux abductovalgus
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
hallux abductovalgus interventions
strengthen intrinsic muscles
Manual therapy of foot and ankle
Modify footwear
Custom orthotics
Splinting
mortons neuroma
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
