Chapter 14 Lower Leg, Ankle, and Foot Conditions

Question 1

What is hallux rigidus, what are its S/S and how would you manage it?

Answer 1

Degenerative arthritis in the first MTP joint
Associated with pain and limited motion
Running and jumping – predispose to injury as a result of degenerative changes resulting from direct injury, hyperextension injury or varus/valgus stress
S/S – tenderness and enlarged first MTP joint, loss of motion, difficulty wearing shoes with elevated heels, restricted toe extension, osteophytes palpated along the dorsal aspect of the metatarsal head
Management
Conservative – ice, low-heeled shows, NSAIDs, therapeutic mobilization, rigid insole
Steroid injections – chronic inflammation
Surgery if conservative treatment fails to resolve symptoms within 6 months

Question 2

What is hallux valgus, what are its S/S and how would you manage it?

Answer 2

Prolonged pressure against the medial aspect of the first MTP joint - leads to thickening of the medial capsule bursa
Results in severe valgus deformity of the big toe
Cause – poorly fitted shoes, heredity, metatarsus primus varus, pes planus, rheumatoid arthritis, neurological disorders
S/S – many individuals asymptomatic, pain over MTP, difficulty wearing shoes, 2nd metatarsal bears more weight
Management – soft shoes with broad toe box and sufficient insole padding, orthoses for longitudinal arch, surgery if conservative treatment fails  4-6 months rehab

Question 3

What is hammer toe?

Answer 3

MTP joint= extension, PIP joint = flexion, DIP joint = extension

Question 4

What is claw toe?

Answer 4

MTP joint = extension, DIP and PIP joint = flexion

Question 5

What is mallet toe?

Answer 5

MTP and PIP joint = neutral, DIP = flexion

Question 6

What are the S/S and what is the management for claw, hammer and mallet toe?

Answer 6

S/S: lead to painful callus formation on dorsum of IP joints
Management: surgery may be necessary

Question 7

What is an ingrown toenail, what are its S/S and what is its management?

Answer 7

Preventable with proper hygiene and nail care
S/S – improper cutting of nail, improper shoe size, nail margins red and painful
Fungal or bacterial infection present – paronychia
Management
Soak toe in water, lift edge of nail and place cotton under to elevate
Soak toe in water and cut a V in the center

Question 8

What is metatarsalgia, what are its S/S and what is its management?

Answer 8

General discomfort around the metatarsal heads
Related to participation in sport, age, arthritic disease, gout, diabetes
S/S – constant overloading of the transverse ligaments leads to flattening of the transverse arch, callus formation, pain in metatarsal region with gradual onset in intensity and duration
Management – reduce load on the metatarsal heads through activity modification, metatarsal pads, strengthen intrinsic muscles of the foot

Question 9

What are bunions, what are its S/S and what is its management?

Answer 9

Found on the medial aspect of the MTP joint of the great toe, can occur on the lateral aspect of the fifth toe (bunionette)
Pronation of the foot, contractures of Achilles tendon, arthritis, ligamentous laxity
S/S – great toe shifts laterally and overlap the second toe, hallux valgus formation, exacerbated by high heels
Management – strapping the great toe in proper alignment, surgery may be needed

Question 10

What is retrocalcaneal bursitis, what are its S/S and what is its management?

Answer 10

External pressure from a constrictive heel cup, coupled with excessive pronation or a varus hindfoot – lead to swelling, erythema and irritation of the retrocalcaneal bursa located between the Achilles tendon and calcaneus
S/S – pain on palpation of the soft tissue anterior to the Achilles tendon, skin thickened, pain with active PF
Management – NSAIDs, stretching Achilles tendon, shoe modifications, calcification of bursa = excision of bursa

Question 11

What is acute compartment syndrome, what are the S/S and what is its management?

Answer 11

Occurs when increased pressure within a limited or nonyielding space compromises the local venous pressure and obstructs the neurovascular network
Caused by a direct blow to the anterolateral aspect of the tibia or by a a tibial fracture
Recent history of trauma, excessive exercise, vascular injury, prolonged externally applied pressure
S/S – increasing severe pain and swelling that appear to be out of proportion to the clinical situation, a firm mass, tight skin, loss of sensation, diminished dorsalis pedis pulse
Immediate action necessary – irreversible damage can occur within 12-24 hours
Management – ice and total rest, compression and elevation not recommended, referral to physician

Question 12

What is turf toe?

Answer 12

sprain of capsular ligament of the first MTP joint from hyperextension of the great toe

Question 13

What is reverse turf toe, what are the S/S and what is the management?

Answer 13

Reverse turf toe – hyperflexion of first MTP joint irritating the dorsal capsular structures
S/S – pain, tenderness, swelling on the plantar/dorsal aspect of the MTP joint of the great toe, tearing of flexor tend
Management – ice, compression, elevation and rest, NSAIDs, protection from excessive motion, taping to limit motion at MTP joint

Question 14

What is an inversion ankle sprain?

Answer 14

Occurs while changing directions rapidly, PF and inversion force
PF – ATFL is taut (first to stretch), CFL is loose
DF – CFL is taught, ATFL is loose

Question 15

What are the clinical findings for a first degree inversion ankle sprain?

Answer 15

First degree – pain and swelling on anterolateral aspect of lateral malleolus, point tenderness over ATFL, no laxity with stress tests

Question 16

What are the clinical findings for a second degree inversion ankle sprain?

Answer 16

Second – tearing or popping sensation felt on lateral aspect, pain and swelling on anterolateral and inferior aspect of lateral malleolus, POP over ATFL and CFL, positive anterior drawer and talar tilt

Question 17

What are the clinical findings for a third degree ankle sprain?

Answer 17

Third – tearing or popping sensation felt on lateral aspect with diffuse swelling over entire lateral aspect with or without anterior swelling, very painful or absent pain, positive anterior drawer and talar tilt

Question 18

What is an eversion ankle sprain?

Answer 18

Injury to the medial ligaments, result from DF and eversion
Associate with fibula fracture, syndesmotic injury or severe lateral ankle sprain
Pronated or hypermobile feet – greater risk
S/S – pain free in all ranges except DF

Question 19

What is a syndesmosis sprain, what are the S/S and what is the management?

Answer 19

External rotation mechanism – fibula and tibia separating disrupting the distal tibiofibular ligament
Longer recovery time
S/S – tender over the anterolateral tibiofibular joint, higher pain and swelling, difficulty weightbearing
Management – non-weightbearing early
Grade I – immobilization in a long, semirigid pneumatic stirrup brace for up to 3 weeks, RTP with taping and heel lift
Grade II – 3-6 weeks non-weightbearing, stabilization in fracture brace for 3-4 weeks followed by a pneumatic stirrup brace for 3 weeks, cold to reduce swelling, RTP delayed up to 3 months

Question 20

What is a subtalar sprain, what are the S/S and what is its management?

Answer 20

CFL, inferior extensor retinaculum, lateral talocalcaneal ligament, cervical ligament, interosseous ligament
Mechanism – dorsiflexion and supination
S/S – ankle turning inward, uncomfortable walking on uneven surfaces, anterior drawer negative unless ankle instability, diagnosis with stress radiographs
Management – strengthen peroneal, proprioceptive rehab

Question 21

What causes a subtalar dislocation?

Answer 21

Results from a fall from a height, foot lands in inversion disrupting interosseous talocalcaneal and talonavicular ligaments
Dorsiflexion and inversion – rupture CFL

Question 22

What are the most common locations for strains and tendinitis in the lower leg?

Answer 22

Achilles tendon proximal to insertion into the calcaneus
The tibialis posterior just behind the medial malleolus
The tibialis anterior on the dorsum of the foot just under the extensor retinaculum
The peroneal tendons just behind the lateral malleolus and at the distal attachment on the base of the 5th metatarsal

Question 23

What are the S/S of strains and tendinitis of the lower leg? What is the management?

Answer 23

S/S – stiffness following period of inactivity, tenderness over tendon, swelling or thickness of tendon, pain with passive stretching
Management – ice massage, AROM, stretching, eccentric strength

Question 24

What are foot strains caused by, what are the S/S and what is the management of it?

Answer 24

Caused by direct blow or chronic overuse, affect intrinsic and extrinsic muscles of foot
Tibialis anterior and toe extensor tendons
S/S – pain, edema, adhesions, pain with stretching, AROM and RROM, crepitus (snowball)
Management – NSAIDs, ROM and strengthening after acute pain subsides

Question 25

What are peroneal tendinopathies, what are the S/S?

Answer 25

Less common MOI – forceful passive DF Retinaculum gives away – tendon slips forward over lateral malleolus S/S – cracking sensation, intense pain, inability to walk, swelling, tender

Question 26

What is posterior tibialis tendon dysfunction?

Answer 26

Loss of support of the spring, deltoid and talocalcaneal interosseous ligament, talonavicular capsule, plantar fascia Common cause of flatfoot

Question 27

What are the clinical findings of stage 1 posterior tibialis tendon dysfunction?

Answer 27

Stage I – pain and swelling along the course of the tendon, pain/tenderness behind medial malleolus, discomfort in longitudinal arch, flatfoot deformity minimal

Question 28

What are the clinical findings of stage 2 posterior tibialis tendon dysfunction?

Answer 28

Stage II – unable to perform a single heel raise, weakness in PF and inversion, tendon is enlarged, elongated, flatfoot with collapsed arch

Question 29

What are the clinical findings of stage 3 posterior tibialis tendon dysfunction?

Answer 29

Stage III – unable to perform a single heel raise and a more severe flatfoot

Question 30

What is the MOI for a gastrocnemius muscle strain?

Answer 30

MOI – forced DF while knee is extended, forced knee extension while foot is dorsiflexed, muscular fatigue, cramping Strain  cramping = dehydration, electrolyte imbalance, fatigue

Question 31

What results in achilles tendon disorders?

Answer 31

Running sports Foot malalignment and biomechanical faults, hyper pronation of foot Tendinosis – cysts Rupture – 30-50 y/o, occur 1-2 inches proximal to distal attachment, pop in posterior ankle

Question 32

What is plantar fasciitis?

Answer 32

Most common hindfoot problem in runners Training errors, improper footwear, unyielding surfaces Pes cavus/planus, decreased PF strength, reduce flexibility of PF, prolonged pronation Overload plantar fascia’s origin on the anteromedial aspect of the calcaneus during weight bearing activities Chronic condition – entrapment of the first branch if the lateral plantar nerve

Question 33

What is medial tibial stress syndrome?

Answer 33

Periostitis along the posteromedial tibial border, usually in the distal third Soleus, flexor digitorum longus and Tibialis posterior Excessive pronation of the foot, changes in training

Question 34

What is exertional compartment syndrome?

Answer 34

Exercise-induced pain and swelling that is relieved my rest Most frequently affected – anterior and deep posterior compartments S/S – tight, cramp-like or squeezing ache, sense of fullness, affects both legs

Question 35

What are venous disorders?

Answer 35

Inactivity following fracture or surgery – venous return to heart from legs becomes reduced Accumulated blood = clot, partial/complete blockages Deep calf veins, popliteal, superficial femoral and iliofemoral vein Embolism – loose thrombus circulates from a larger vessel to smaller one Risk factors – smoking, obesity, inactivity Positive Homan’s sign

Question 36

What is plantar interdigital neuroma?

Answer 36

trauma or repetitive stress caused by tight-fitted shoes or pronated feet lead to pressure on plantar digital nerves Between 3rd-4th metatarsals S/S – pain improves when activity is stopped or shoe is removed

Question 37

What is tarsal tunnel syndrome?

Answer 37

posterior tibial nerve or one of its branches, becomes constricted beneath the fibrous roof of the flexor retinaculum of the foot Causes – ganglions, cariosities, lipomas, tenosynovitis, fibrosis S/S – NTB around medial malleolus radiation to sole and heel, DF and ER and eversion increases pain

Question 38

What is sural nerve entrapment?

Answer 38

numbness and decreased temperature along dorsolateral aspect of foot

Question 39

What is Freiberg disease?

Answer 39

Painful avascular necrosis of the second or third (rare) metatarsal head 14-18 year old adolescents before closure of the epiphysis S/S – diffuse pain in forefoot

Question 40

What is Sever disease?

Answer 40

7-10 year old children It is associated with growth spurts, decreased heel cord, h/s flexibility Apophyseal plates is vertically oriented, susceptible to shearing stresses from the gastrocnemius

Question 41

What are stress fractures?

Answer 41

Running/jumping activities Women with amenorrhea or oligomenorrhea Noncritical – medial tibia, fibula, 2-4 metatarsals Critical – high rate of non-union, anterior tibia, medial malleolus, talus, navicular, 5th metatarsal and sesamoids

Question 42

What are avulsion fractures?

Answer 42

Occurs at the site of any ligamentous or tendinous attachment Result of sudden powerful twist or stretch of the body part Eversion ankle sprains – deltoid ligaments Inversion ankle sprains – plantar aponeurosis, peroneus brevis tendon

Question 43

What is an osteochondral fracture of the talus?

Answer 43

Severe ankle sprains can impinge the dome of the talus against the malleoli, leading to a fracture of the cartilaginous cover Anterolateral fractures – 43% of lesions – forceful inversion and DF Wafer-shaped Posteromedial fractures – 57% of lesions – forceful inversion and PF Cup-shaped S/S – deep nonspecific pain, instability, crepitus, locking

Question 44

What are tarsal fractures?

Answer 44

Lisfranc injury – involves disruption of the tarsometatarsal joint, with or without an associated fracture Severe twisting S/S – 1st metatarsal dislocated from first cuneiform, four metatarsals laterally displaced Management – short-leg, non-walking cast for 6 weeks

Question 45

What is a Tib-Fib fracture?

Answer 45

Inversion sprain – the medial malleolus fractured at the level of the talar dome or spiral fracture at the distal tibial metaphysis Maisonneuve fracture – eversion-type injury to the ankle, associated fracture of proximal third of fibula