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SCS > Ankle/Foot > Flashcards

Ankle/Foot Flashcards

1
Q

Peroneal Tendon Dysfunction

A

Pain in posterolateral ankle and/or along course of tendons.
1. Often overlooked cause of persistent lateral ankle pain after ankle sprains
2. Very often these patients have cavo-varus hindfoot with high arch

Orthotics: OTC insole with lateral support in mid foot and rear foot. If not successful, custom made with lateral posting in heel and possibly forefoot.

Can diagnose with MRI or US.

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2
Q

Common stress fracture sites by sport

A
  1. Navicular predominates in track
  2. Tibia in distance
  3. Metatarsals in dancers
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3
Q

Risk factors for stress fractures

A
  1. Female
  2. Amenorrhea for more than 6 months
  3. Menstrual irregularity
  4. H/O stress fractures
  5. Nutritional status (low calcium, fiber, protein, alcohol, caffeine)
  6. Family h/o osteoporosis
  7. Low sex hormone in males
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4
Q

Foot and leg posture and its role on stress fractures

A
  1. High arches predisposes for femoral and tibial stress fractures
  2. Pes planus predisposes to metatarsal stress fractures
  3. Longer leg may predispose to stress fractures on that side (except for increased risk of fibular on the shorter side)
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5
Q

Critical versus non-critical stress fracture sites

A
  1. Non-critical: medial tibia, fibula, and metatarsals 2, 3, and 4
  2. Critical (higher rate of non-union and surgery usually recommended as 1st line Rx): anterior tibia, medial malleolus, talus, navicular, fifth metatarsal base, and sesamoids
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6
Q

Managing stress fractures

A

Depending on severity, usually decreased or NWB for 1-2 months. Return to full sport usually achieved within 6-8 weeks.

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7
Q

Tibial stress fractures

A

Medial tibia is non-critical, may see high/stiff arches (incapable of absorbing load) or flat foot that causes muscle fatigue. Anterior tibia is critical and could require rest or immobilization up to 4-6 months. If no evidence of healing after this point may consider surgery (drilling, bone grafting, or rod).

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8
Q

Navicular stress fractures

A

Critical region. Very often tender in the proximal, dorsal portion of navicular. Usually will be NWB for 6 weeks. If there is point tenderness still, another 2 weeks may be required. If not responding to conservative treatment, may undergo surgery for screw fixation, with or without bone grafting.

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9
Q

Metatarsal Stress Fractures More Concerning

A

Base of 2nd (most often in ballet dancers) and proximal 5th. 3 types of proximal 5th fractures: tuberosity avulsion (most common; from peroneus brevis), jones (at junction of metaphysis and diaphysis), and diaphysial. Avulsion fracture only needs short period of immobilization. Jones and diaphyseal are more critical and require 6-10 weeks NWB, if this fails may need screw implanted.

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10
Q

Sesamoid Stress Fractures

A

Medial is more commonly affected. FHB goes through them, protects FHL. MRI can help differentiate bipartite vs fractures sesamoid. These are prone to non-union. Usually do NWB for 6 weeks, can use a sesamoid pad. Can also remove if nonunion or splintering occurs.

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11
Q

Exertional compartment syndrome

A

Reversible ischemia in the lower leg that occurs with increased pressure from exercise and decreases with rest. Over time an ache still may be present even after stoping activity. Only way to confirm is by doing exercise and then checking compartment pressure in one or more of the compartments of the leg. It feels like a squeezing, cramping, aching sensation and relieves with rest. May be tender during palpation of compartment. Usually needs surgery but conservative tried first. If push through pain could lead to acute compartment syndrome. Each of the 4 main compartments has a main nerve: anterior = deep peroneal, lateral = superficial peroneal, superficial posterior = sural, deep posterior = posterior tibial. Most common are anterior (95% of cases) and deep posterior compartments.

Sx’s
Anterior = weak DF of ankle/toes and sensory of dorsal 1st web space
Deep Posterior = weak PF, weak toe flexion and foot inversion and plantar foot paresthesias
Lateral = weak ankle version and sensory of anterolateral leg
Superficial Posterior = sensory of dorsolateral foot

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12
Q

Rehab after fasciotomy for compartment syndrome

A

Use of compression dressing. Crutches for comfort for a few days but doing AROM/PROM right away. Once wound is healed then cycling/walking/biking can resume. Light jog after about 2 weeks and resume training in 6 weeks.

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13
Q

Talk about shin splints

A
  1. Also called medial tibial stress syndrome.
  2. Thought to be more periostalgia or tendinopathy along tibial attachment of tibialis posterior or soleus muscles
  3. TTP of posteromedial, distal 1/3 of tibia (usually more than 5 cm)
  4. With mild cases there is usually only pain with exercise. In severe cases there is pain during rest.
  5. Plain films are negative
  6. Can differentiate from stress fracture with 10 hop test (shin splints can do this, stress fracture usually cannot)
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14
Q

Differential for shin splints

A
  1. Stress fracture; pain is usually very focal and medial tibial stress syndrome the pain is more diffuse along bone (palpation will reflect this. For shin splints a bone scan will show vertical linear increase in activity along tibial periosteum, stress fracture shows more focal fusiform increase with radiotracer uptake.
  2. Compartment syndrome
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15
Q

Contributing factors for shin splints

A

Thought to be:
1. Increased valgus forces (rear foot, pronation, femoral anteversion)
2. Pes planus or cavus
3. Limb length difference

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16
Q

Treatment for shin splints

A
  1. Avoid hill running or uneven surface running
  2. Proper shoes to minimize rear foot valgus or pronation
  3. Orthotics
  4. Flexibility/strengthening
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17
Q

Imaging for stress fractures of the foot? When is each most appropriate? Where might you see false negatives.

A
  1. Radiographs, MRI, bone scans
  2. Radiographs usually used initially but 2/3 are initially negative and only 1/2 ever develop radiographic findings. Bone scan or MRI used to confirm diagnosis. Bone scans will confirm within 2-8 days after onset of symptoms. MRI can help grade the stage of the condition.
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18
Q

Turf Toe
1. What is it
2. How do you diagnose it clinically
3. How is it managed

A

Hyperextension injury to plantar plate and sesamoid complex of big toe. Diagnosed with inability to hyperextend MTP without pain (vertical Lachman’s will show greater laxity).
1. Want to try and limit DF of great toe and decrease abnormal pronation of foot
2. Orthotics: A TCO (total contact orthotic) made of carbon fiber could help limit hallux DF
3. Shoes: May want to look into rocker sole or extended steel shank between layers of shoe sole

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19
Q

Morton’s Neuroma

A
  1. Orthotics: Goal is to relieve excessive pressure under 2nd met head. A TCO (total contact orthotic) with metatarsal pad proximal to 2nd (& maybe 3rd) to help relieve 2nd met head pressure. You could also try to increase pressure on 1st met head with Morton’s extension that has posting under 1st met head/shaft.
  2. Shoes: a full length steel shank or anterior rocker bottom may be helpful in reducing bending at MTP
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20
Q

Bunion

A
  1. Shoes: may need to stretch more room for the bunion
  2. Orthotics: If due to excessive pronation, may need TCO with medial posting
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21
Q

Metatarsalgia

A
  1. Orthotics/footwear: Limit motion in this area with TCO that has firm posting material (like cork) or use rocker shoe or extended steel shank
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22
Q

Orthotics/shoes for Pes cavus

A

Want to provide support/cushion, especially at heel and prominent metatarsal heads. OTC insoles can work and could add metatarsal pad under 1st and 5th met heads (or either individually). Custom inserts are indicated if this doesn’t work. Could use additional posting on lateral aspect of forefoot (in cases of forefoot valgus: everted position of forefoot).
Shoes: may want curved last to accommodate for shape of foot

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23
Q

Orthotics/shoes for Pes planus

A
  1. OTC insoles with added medial support under medial rear foot, and/or arch, and/or forefoot
  2. Should be firmer materials for orthotics
  3. Shoes: straight last with motion control (reinforced heel counter and medial midsole reinforcement)
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24
Q

Orthotics/Shoes for Posterior Tibial Tendonitis

A

Same as for Pes planus:

  1. OTC insoles with added medial support under medial rear foot, and/or arch, and/or forefoot
  2. Should be firmer materials for orthotics
  3. Shoes: straight last with motion control (reinforced heel counter and medial midsole reinforcement)
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25
Q

Orthotics for plantar fasciitis

A

Can be associated with Pes planus or cavus so using orthotic to accommodate for whichever type foot.

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26
Q

Swelling and likelihood of fracture with LAS

A

The extent of effusion does not necessarily indicate the presence or absence of a fracture

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27
Q

Impairments found after ankle sprain

A
  1. Abnormal muscle timing (ankle, knee, and hip)
  2. Decreased strength at ankle and hip
  3. Decreased proprioception at ankle
  4. Decreased DF ROM
  5. Increased subtalar and mid foot motion
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28
Q

Risk factors for ankle sprain

A
  1. History of LAS with decreased ankle DF
  2. Not warming up properly
  3. Not using external support (bracing and taping)
  4. Not participating in neuromuscular retraining
  5. Females
  6. Hip abductor and extensor weakness
  7. Poor performance on balance and hop tests
  8. Participating in court sports
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29
Q

Risk factors for going on to develop CAI

A
  1. Not using prophylactic bracing
  2. Not participating in exercise-balance program
  3. Higher BMI
  4. Poor functional performance after LAS
  5. Participating in sports
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30
Q

Best special tests for diagnosis lateral ankle sprain

A
  1. RALDT is the best
  2. Adding palpation of the talus during ADT to assess for how much it translates anteriorly makes it more sensitive
  3. ALDT (one study showed a little better than ADT)
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31
Q

Ottawa Ankle/Foot Rules

A

Mnemonic: 44-55-66PM

  1. Inability to both of the following: take 4 steps initially and 4 steps in ER
  2. TTP at base of 5th met or navicular
  3. TTP at posterior 6 cm of medial or lateral malleolus
32
Q

“Usual” time to return to sports after ankle sprain (many can take longer)

A

1 day to 3-4 weeks but generally patients are usually treated non-surgically for 4-6 weeks. In cases of partial/total rupture, may take 6-8 weeks.

33
Q

What does research say about taping and bracing for ankle sprains?

A
  1. Primary Prevention (prior to any ankle sprain): Should be used, especially if you have risk factors for LAS
  2. Secondary prevention (to prevent this again): Should be used
  3. Tertiary Prevention (During acute episode): Should be used with progressive WB.
  4. Tertiary Prevention (During chronic episode): You shouldn’t do external support as a stand-alone treatment
34
Q

Role of neuromuscular re-education in ankle rehab?

A

For ankle sprains, you should use this for recurrent ankle sprains but there is a lack of evidence for this to prevent first time ankle sprains.

35
Q

Does footwear help decrease risk for ankle sprains?

A

Footwear modifications and orthotics have shown to be ineffective for prevention of further ankle sprains.

36
Q

How should patient be managed after ankle sprain?

A
  1. Early WB
  2. Don’t immobilize but a period of immobilization could be used in cases of SEVERE ankle sprain (don’t do this more than 10 days though)
  3. Use early NRE and proprioceptive exercises
37
Q

How does RICE do for treatment of ankle sprains?

A

It is insufficient alone to improve function and injury recurrence.

38
Q

Most common sites for stress fractures in leg/foot/ankle

A

Most common in tibia, next is 2nd metatarsal

39
Q

Clinical presentation of symptoms with stress fractures

A

Initially will only hurt during the activity but once progresses will become more constant (night and rest). Pain is usually very focal/pinpoint (within 1 finger). Hurts with weight bearing and usually associated with increase in activity.

40
Q

Anterior ankle impingement

A

Entrapment of structures at anterior tibiotalar joint in terminal dorsiflexion. Pain caused by osteophytes or entrapment of soft tissues.

A soft tissue mass of adipose and synovial tissues exists in the anterior joint space. These tissues are compressed after 15 degrees of DF in asymptomatic individuals.

Anterolateral more seen with forced DF and eversion.

Surgery could be used as the first option for high-level athletes who need to get back fast.

41
Q

Posterior ankle impingement

A

Compression of structures posterior to the tibiotalar and talocalcaneal joints in terminal plantarflexion. Pain caused by osteophytes or entrapment of soft tissues. Common in dancers, kickers, jumpers.

May compress FHL, posterior capsule, posterior synovium, os trigonum.

Surgery could be used as a first option for those athletes who need to get back fast.

42
Q

Subtalar ranges of motion

A

0-35 inversion
0-25 eversion

43
Q

Lisfranc Injury

A

A tarsometatarsal disruption due to ligament rupture or fracture characterized by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal. Injuries can range from mild sprains to severe dislocations

44
Q

Lisfranc injury mechanism

A

Most Common: Axial load on plantarflexed and slightly rotated foot

Secondary: Plantarflexion with fixed forefoot into abduction

45
Q

Lisfranc ligament

A

an interosseous ligament that goes from medial cuneiform to base of 2nd metatarsal on plantar surface

46
Q

Lisfranc treatment

A

Non-operative if there is no displacement with/without weight bearing. If there is ANY displacement then non-operative outcomes aren’t great and surgery is the best option. Surgery may be percutaneous pinning, ORIF, or arthrodesis.

47
Q

Calcaneal fractures

A

Most common tarsal bone fractured. Stress fracture: immobilized/NWB 6 weeks. Fracture: 10-12 weeks.

48
Q

Metatarsal fracture

A

Typically a crush injury or forefoot planted and rest of leg rotating. Base of 2nd met stress fracture can be seen in dancers. Can cause Lisfranc injury.

49
Q

Radiographic findings with plantar fasciopathy

A

May see bony exostosis at medial calcaneal tuberosity but usually x-rays don’t help with diagnosis.

50
Q

Plantar fasciopathy findings

A

Isolated gastroc tightening.

51
Q

Hallux Rigidus

A

Pain and loss of motion at 1st MTP due to OA. Diagnosis make with radiographs and may show narrowing or dorsal osteophytes. Treatment with Morton’s extension orthotic (carbon fiber, prevents bend).

52
Q

Claw, Mallet, and Hammer Toes

A

Claw = MTP extension, PIP/DIP flexion
Hammer= slight MTP extension, PIP flex, DIP ext
Mallet = DIP flexion

53
Q

Claw Toe Management

A

May have callus under met head. Plantar padding with metatarsal or crest pads or orthotics to offload plantarly-subluxed met heads

54
Q

Treatment for mallet toe

A

Shoe with high toe box, silicone/foam toe sleeves

55
Q

Tarsal Tunnel Syndrome

A

Compressive neuropathy of posterior tibial nerve. The tunnel is below the flexor retinaculum, just behind/below medial malleolus. May have weakness/atrophy of small foot muscles and loss of sensation on bottom of foot. Relatively uncommon. Pes planus/hyperpronation may contribute. May have pain with Tinel’s and forced eversion/DF.

56
Q

Posterior tibial tendon dysfunction

A

Insufficiency in this is the most common cause of adult-acquired flat foot. Usually pain in the medial ankle but as this progresses it can shift to the outside of the foot and ankle (severe: fibula touching calcaneus). They have significantly increased EMG activity in 2nd half of stance phase. Tibialis posterior acts as the primary dynamic stabilizer of the medial longitudinal arch and main invertor of midfoot. With heel raise these patients may not have hindfoot inversion like they are supposed to. Strengthening and orthotics with medial posting advised. May need immobilization for 3-4 weeks.

57
Q

Posterior Tib Insertion

A

Close to its insertion site the tendon splits into a main, plantar and recurrent components, with the main component inserting onto the navicular tuberosity, the plantar portion onto the second, third, fourth metatarsals, second and third cuneiforms and cuboid. The recurrent component attaches to the sustentaculum tali of the calcaneus.

58
Q

Foot Posture Index

A

6 Things to rate from -2 to +2 (5 ratings)
1. Can you palpate medial and lateral talus equally
2. Look at the lateral malleolus, are the infra and supra-malleolar curves roughly equal
3. Is calcaneus vertical
4. Prominence of TNJ (flat)
5. Arch height normal and concentrially curved
6. Medial and lateral toes equally visible

59
Q

How often should runners change their shoes?

A

Every 250-500 miles, a distance where most shoes lose up to 40% of their shock-absorbing capabilities

60
Q

Osteochondral Defects of Talus

A

Focal injury to Tamar dome with variable involvement of subchondral bone and cartilage. Medial talar dome more common, can occur during ankle sprain.

61
Q

What makes up the deltoid ligament?

A
  1. Posterior Tibiotalar
  2. Tibiocalcaneal
  3. Tibionavicular
  4. Anterior tibiotalar ligaments
62
Q

What are the ligaments of the distal tib-fib joint

A
  1. Anterior-inferior
  2. Posterior-inferior
  3. Transverse tibio-fibular
  4. Interosseus membrane and ligament
  5. Inferior transverse ligament
63
Q

Lateral ligaments of the ankle

A
  1. Anterior Talofibular ligament
  2. Calcane-fibular ligament
  3. Posterior Talofibular ligament
64
Q

Talar Tilt Test

A

Usually used for calcaneofibular ligament. Support tibia with foot in 10-20 degrees PF. Try to just invert the hindfoot. The lateral aspect of talus is palpated and look for increased motion.

65
Q

Squeeze Test

A

Sn = 30, Sp = 93.5 for high ankle sprain. Compress proximal fibula and tibia.

66
Q

Posterior Drawer Test

A

For posterior talofibular ligament.

67
Q

High Ankle Sprain

A

Involves the ligaments of the distal tibia and fibula. Most commonly occurs with extreme external rotation or DF. The dome of talus is wider anteriorly than posteriorly and these movements force apart medial and lateral mortise. Can twist leg into ER in bottom of pile or hit someone from lateral knee while foot is planted. There will be less swelling than lateral ankle sprain. They will demonstrate inability to fully PF and bear weight. TTP at anterior tibiofibular ligament. Need to rule out fracture (palpate bones). Treated conservatively if no diastasis. If diastasis is latent and seen later with CT/MRI, may potentially be okay with walking boot for 4-6 weeks. If diastasis immediately, will need surgery. This usually takes twice as long to recover compared to typical ankle sprain.

68
Q

Subungal Hematoma

A

Bleeding under toenail due to separation of nail plate from nail bed. Get wider toebox, remove irritation, sometimes may need to remove blood by drilling needle through toe nail.

69
Q

Keystone to tarsometatarsal arch?

A

Base of the 2nd metatarsal

70
Q

ROM of the tarsometatarsal articulation and indications there is disruption?

A

This articulation is restricted to motion in the plantar direction with flexion and extension. Because of this, displacement in any other direction is a clear sign that there has been a fracture of the 2nd metatarsal base or disruption of stabilizing ligaments.

71
Q

Ligaments for tarsometatarsal articulation?

A
  1. Strong inter metatarsal ligament runs between bases of 2-5 (nothing between 1 and 2)
  2. Lisfranc ligament between MEDIAL (yes, most medial and not MIDDLE) and base of 2nd (this ligament is largest of tarsometatarsal articulation (runs in a plantar direction to stabilize 2nd met in its mortise). The Lisfranc ligament and plantar ligaments are significantly stronger than the dorsal ligaments.
72
Q

Normal radiograph position for tarsometatarsal joint?

A

Medial border of 2nd met aligns with medial border of middle cuneiform

Medial border of 4th met aligns with medial border of cuboid

73
Q

Radiographs for Lisfranc

A

Can do these in WB and NWB. Medial borders of 2nd met/middle cuneiform and 4th met/cuboid line up.

Look for diastasis between 1st/2nd Mets during WB (won’t always see in NWB)

74
Q

Clinical Diagnosis of Lisfranc Injuries?

A
  • Usually midfoot pain
  • May have midfoot swelling, tenderness
  • May have plantar ecchymosis
75
Q

Treatment of Lisfranc Injuries

A

Stage 1 (no diastasis or loss of arch height on WB radiographs): Can be reliably treated with cast immobilization (even if having the sx’s for several months already) for 4-6 weeks.

Stage 2 (2-5 mm diastasis between 1st/2nd Mets but no loss of arch height): Early ORIF with screws

Stage 3 (Diastasis between 1st/2nd Mets and loss of arch height): ORIF with screws

SCS (27 decks)

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