Ch 4 - MSK: Ankle and Foot Flashcards
What is the most commonly injured ankle ligament?
Anterior talofibular ligament (ATFL)
What is the primary lateral ankle ligament stabilizer?
Anterior talofibular ligament (ATFL)
What are the lateral ankle ligaments?
– Anterior talofibular ligament (ATFL)
– Calcaneofibular ligament (CFL)
– Posterior talofibular ligament (PTFL)
What are the deep components of the deltoid ligament?
■ Anterior tibiotalar
■ Posterior tibiotalar
What are the superficial components of the deltoid ligament?
■ Tibionavicular
■ Tibiocalcaneal
What are the components of the medial longitudinal arch of the foot?
■ Spring ligament (plantar calcaneonavicular ligament)
■ Medial and posterior talocalcaneal ligaments
What are the Syndesomotic ligaments?
- Anterior tibiofibular ligament
- Posterior tibiofibular ligament
- Transverse tibiofibular ligament
- Interosseous ligament
What are the muscles and innervation of toe flexion?
– FDL – FHL – FDB – FHB – Quadratus plantae – Interossei – Flexor digiti minimi brevis – 1st lumbrical – 2nd-4th lumbricals
What are the muscles and innervation of toe extension?
– Extensor digitorum longus – Extensor hallucis longus – Extensor digitorum brevis – 1st lumbrical – 2nd-4th lumbricals
What are the muscles and innervation of toe abduction?
– Abductor hallucis
– Abductor digiti minimi
– Dorsal interossei
What are the muscles and innervation of toe adduction?
– Adductor hallucis
– Plantar interossei
What is the MOI for lateral ankle sprains?
Inversion of a plantar-flexed foot places the foot in the most vulnerable position to cause ligamentous injury
What does the anterior drawer test of the ankle examine?
Integrity of ATFL
What does the talar tilt test of the ankle examine?
Integrity of CFL and ATFL
What is a grade I ankle sprain?
– Partial tear of ATFL – CFL and PTFL intact – Mild swelling with TTP at lateral ankle – No instability – Stress tests negative
What is a grade II ankle sprain?
– Complete tear of ATFL
– Partial tear of CFL
– Diffuse swelling/ ecchymosis
– (+) Anterior drawer
What is a grade III ankle sprain?
– Complete tear of the ATFL and CFL
– (+) Anterior drawer
– (+) Talar tilt
What x-ray views should be done in ankle sprain?
AP, lateral, oblique and stress views: Anterior drawer and talar tilt
What indicates rupture of all 3 ankle ligaments on x-ray?
Tilting more than 30°
What is the treatment for grade I and II ankle sprain?
■ RICE, NSAIDs, analgesics, immobilization
■ Early mobilization
■ PT: ROM, strengthening, proprioceptive exercises, taping, and bracing
■ Modalities: Moist heat, warm whirlpool, contrast baths, ultrasound, short wave diathermy
What is the treatment for grade III ankle sprain?
■ 6 mo trial of rehab and bracing
■ Ligament repair, tenodesis of the peroneus brevis.
What are indications for surgery in ankle sprain?
Large bony avulsions
Severe ligamentous damage
Severe recurrent injuries
What is the MOI for peroneal tenosynovitis or rupture?
Repetitive forceful eversion
What is the MOI for peroneal subluxation or dislocation?
Sudden dorsiflexion of the ankle
Skiing injury
What is the clinical presentation of peroneal tenosynovitis?
Painful swelling in the lateral retromalleolar area along the course of the peroneal tendons
What is the clinical presentation of peroneal rupture, subluxation or dislocation?
Sudden weakness with the inability to actively evert the foot
What is the treatment of peroneal rupture, subluxation or dislocation?
Orthopedic evaluation
4 to 6 weeks of immobilization in a plantar-flexed position
What is the MOI of a medial ankle sprain?
Foot caught in a pronated, everted position with internal rotation of the upper body
What are the grading scales for medial ankle sprain?
- Grade 1: Stretch
- Grade 2: Stretch partial tear
- Grade 3: Full tear
What are complications of medial ankle sprain?
Syndesmosis ankle injuries
Maisonneuve fractures
What is the MOI of tibialis posterior tenosynovitis?
Repetitive forceful inversion
Hyperpronation
What is the clinical presentation of tibialis posterior tenosynovitis?
- Insidious onset of posteromedial ankle pain
- Medial hind foot swelling
- Pain with push-off
- Weakness with inversion and plantar flexion
What exam finding is seen with tibialis posterior rupture?
“Too many toes” sign
From behind more toes are visible on the affected side 2/2 collapse of the medial longitudinal arch
What is Malicious malalignment syndrome?
Broad pelvis Inc femoral anteversion Squinting patellae Excessive Q angle Excess pronation of the foot
What is the MOI of Achilles tendonitis?
Repetitive eccentric overload
What are causes of Achilles tendon rupture?
– Inflammatory: microruptures of collagen fibers
– Vascular: Inadequate vascularization 2 to 6 cm proximal to the insertion of the tendon
– Mechanical: Sudden push-off with the foot in the extension position
What are anatomic causes of Achilles tendonitis?
Hyperpronation
Tight hamstrings and heel cords
Pes cavus
Genu varum
What exam finding is indicative of an Achilles tendon rupture?
Positive Thompson’s test
What is the treatment of Achilles tendonitis?
– Rest, NSAID
– Short-term immobilization, stretching, strengthening, heel lifts.
Where do most Achilles tendons rupture?
Area of hypovascularity 2 to 5 cm proximal to the tendon insertion
What is the conservative management of Achilles tendons rupture?
Bracing in a plantar- flexed position for a period of 8 to 12 weeks and dorsiflexion gradually inc to neutral by end of 12 weeks
What is the surgical management of Achilles tendons rupture?
Tendon repair with cast for 2 weeks and then plantar flexion dial lock brace for 4 to 6 weeks, which is slowly brought to neutral
What is dancer’s tendonitis?
Flexor hallucis longus tendonitis
What is the MOI of Flexor hallucis longus tendonitis?
Repetitive push-off maneuvers causing inflammation of the synovium or tendon as it courses in the groove of the sustentaculum tali and behind the lateral malleolus to its insertion
What is the clinical presentation of Flexor hallucis longus tendonitis?
- TTP of tendon at the posteromedial aspect of the great toe
- Dec ability to flex the great toe
- Inc pain with active plantar flexion and passive dorsiflexion
What is the MOI of retrocalcaneal/calcaneal apophysis bursitis?
Repetitive pressure and shearing forces causing thickening and inflammation of the bursae
What is Haglund’s deformity?
Enlargement of the posterosuperior tuberosity
What is Sever’s disease?
Apophysitis, an independent area of ossification separated from the main bone at the cartilaginous plate
What is the MOI of a tibiofibular syndesmosis injury?
- Hyperdorsiflexion and forceful eversion of the ankle
* Direct blow to the foot with the ankle held in ER
Describe the stress test for tibiofibular syndesmosis injury.
Knee 90° and ankle neutral, the patient experiences pain when the examiner attempts forcefully ER foot
What is a Maisonneuve fracture?
Rupture of the anterior tibiofibular ligament extending through the interosseous membrane, which often results in a proximal fibula fracture
What is sinus tarsi syndrome?
Talocalcaneal ligament sprain
What is the MOI of sinus tarsi syndrome?
- Excessive foot pronation causing adduction of the talus
- H/o arthritis: RA, gout, and seronegative spondyloarthropathies
- History of prior ankle injury
What is the clinical presentation of sinus tarsi syndrome?
Pain on the anterolateral aspect of the foot and ankle in the area of the sinus tarsi
What is tender on exam of tibialis anterior tendon injury?
TTP insertion onto the medial aspect of the base of the 1st metatarsal and the 1st cuneiform bones and proximally along the tendon to the muscle belly on the lateral side of the tibial shaft
What is the clinical presentation of tibialis anterior tendon injury?
- Painless foot slap that has gradually inc
- Inc tenderness and weakness with active dorsiflexion and passive plantar flexion
- Palpable defect over the anterior aspect of the ankle
What is a SPlit Anterior Tibial Tendon Transfer (SPLATT)?
TA tendon is split, and a portion transferred to the lateral foot. Half remains attached to origin, while the distal end of the lateral half of the tendon is tunneled into the 3rd cuneiform and cuboid bones
*Used for TA spasticity
What does a SPlit Anterior Tibial Tendon Transfer (SPLATT) provide?
Eversion force to counteract the dynamic varus deformity to provide a flat base for WB
*Used for TA spasticity
What is the MOI of a talar neck fracture?
- Eversion and dorsiflexion
* Inversion and plantar flexion
What is a Hawkin’s Classification type I talar fracture?
Nondisplaced vertical fracture of the talar neck
What is a Hawkin’s Classification type II talar fracture?
Displaced fracture of the talar neck of the subtalar joint with the ankle joint remaining intact
What is a Hawkin’s Classification type III talar fracture?
Displaced fracture of the talar neck with dislocation of the body of the talus from the subtalar and ankle joint
Where does AVN occur in talar fracture?
Talar body
What are associated disorders with plantar fasciitis?
HLA-B27 Seronegative spondyloarthropathy. Heel spurs 50% to 75% Pes cavus Pes planus Obesity Tight Achilles tendon
What is the clinical presentation of plantar fasciitis?
- TTP medial heel at the origin of the plantar fascia and along plantar arch
- Pain w/ hyperextension of the great toe
- Pain worse in morning or at start of WB and dec during activity
- Tight Achilles tendon
What can steroid injection for plantar fasciitis lead to?
Superficial fat pad necrosis
What is the most common location of Morton’s neuroma?
3rd intermetatarsal space (b/w 3rd and 4th digits), followed by the 2nd intermetatarsal space
What is the clinical presenation of Morton’s neuroma?
- Sharp shooting forefoot pain radiating to the affected digits
- Dysesthesias and numbness
- Isolated pain on the plantar aspect of the web space
Describe the exam for Morton’s neuroma.
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
Describe modifications for treatment of Morton’s neuroma.
– Adequate insole cushioning, wide toe box, low heel height
– Metatarsal pads
What is turf toe?
Metatarsal phalangeal (MTP) sprain
What is hallux valgus?
Lateral deviation of the 1st toe
Normal angle of 15° b/w the tarsus and metatarsus
What can hallux valgus cause?
Painful prominence of the medial aspect of the MTP joint (bunion)
What is hallux rigidus?
Degenerative joint disease of the first MTP joint leading to pain and stiffness
What is a hammer toe?
Deformity of the lesser toes in which there is flexion of the PIP joint
What is the treatment of a hammer toe?
- Shoes with high toe boxes and 1/2 inch longer than the longest toe
- Passive manual stretching
What is a claw toe?
Extension of MTP, flexion of the PIP, and flexion of the DIP
What is the cause of a claw toe?
Weak foot intrinsic muscles
What is the treatment of a claw toe?
- Shoes with soft insoles and high toe boxes
- Splint
- Surgical correction
What is a mallet toe?
Flexion deformity at the DIP joint with normal alignment at the PIP and MTP joints
What is the treatment of a mallet toe?
- Shoes with soft insoles and high toe boxes
- Trim callus
- Flexor tenotomy
What is the MOI of a Lisfranc joint injury?
Direct impact to the joint or by axial loading of the midfoot and rotating it
What is the treatment of a Lisfranc joint injury?
– Nondisplaced joint: NWB, immobilization for 6 to 8 weeks
– Surgical stabilization is integral to maintaining the bony architecture of the entire foot
What is a Jones fracture?
Transverse fracture through the base of the 5th metatarsal
What is a Nutcracker fracture?
Cuboid fracture
What is a March fracture?
Metatarsal stress fracture
What is the treatment of a Jones fracture?
– NWB cast for 6 wk
– ORIF if nonunion
What is the treatment of a Nutcracker fracture?
ORIF
What is the treatment of a March fracture?
– Relative rest with immobilization
– Cast if needed
– 5th metatarsal may require surgical fixation due to the increased risk of fracture displacement
What is the treatment of a turf toe?
Firmer toe box shoes
Taping
Immobilization by 1st metatarsal splints or orthoplast inserts
