Clinical Syndromes of the Foot & Ankle Flashcards
Sever’s Disease
- What is it = ?
- Treatment = ?
Clinical Syndromes
Sever’s Disease: Calcaneal traction apophysitis
(Osgood- Schlatters of the heel).
- Inflammation of an open growth plate
- Typically with boys in growth phase. Average age of onset is 8-13 years
- High levels of athletic participation. Reduced flexibility in gastroc/soleus. Other reported risk factors include improper footwear, a greater body mass index, greater waist circumference, higher weight, and increased height.
- Acute episodes usually resolves in 2-4 weeks but can continue
- Treatment:
- Rest, ice, heel lift or shoe inserts
- Gastroc/soleus stretching
Fibularis Tendinopathy / Subluxation
- Associated with = ?
- Treatment = ?
Clinical Syndromes
Peroneal / Fibularis Tendinopathy / Subluxations:
- Often associated with lateral ankle sprains and contribute to functional ankle instability.
- Subluxation of the fibularis tendons can occur
- Often have pain with eversion and heel raises.
- Subluxation test: Dorsiflexion with eversion
- Peroneal Subluxation Test
- Treatment is limited surgery is often necessary – minimal evidence
- Protect tendon
- General strengthening and balance
- orthotics
Entrapment of the tibial nerve is it passes through the posterior portion of the medial malleolus = ?
Clinical Syndromes
Tarsal Tunnel Syndrome:
- Medial and lateral plantar branches may be involved.
- Gradual Onset
- Could be due to over pronation
- (+) Dorsiflexion Eversion Test
- Possible (+) SLR with DF
- Treatment: orthotics, strengthening and nerve gliding
Test assessing for tibial nerve entrapment = ?
Clinical Syndromes
Tinel’s Sign: Assessing for tibial nerve entrapment.
Dorsiflexion eversion test, test for = ?
Clinical Syndromes
Dorsiflexion Eversion Test - Tarsal Tunnel Syndrome (Posterior tibial nerve):
- Dorsiflexion eversion test
- Posterior tibial nerve
- Pain seems to be more sensitive than numbness as a positive test.
Triple compression test, test for = ?
Clinical Syndromes
Triple Compression Special Test for Tarsal Tunnel Syndrome.
What am I = ?
- Typically seen in middle aged - older adults
- Medial Sided ankle and foot pain
- Can’t perform or have difficulty with a heel raise
Clinical Syndromes
Posterior Tibial Tendinopathy:
- Medial Sided ankle and foot pain.
- The Posterior tibialis works to support the arch of the foot. It works eccentrically.
- Degenerative changes in the posterior tibialis tendon becoming insufficient. So this is typically seen in middle aged to older adults.
- Associated with flat feet or pronation of the foot.
- Often can’t perform or have difficulty with a heel raise when it becomes severe.
- Gastroc/soleus complex is often tight
Posterior Tibialis Tendon Dysfunction
- Stage 1 = ?
- Stage 2 = ?
- Stage 3 = ?
Clinical Syndromes
Posterior Tibialis Tendon Dysfunction:
- Stage 1:
- Tenderness to palpation
- Swelling
- Pain with heel raise
- Stage 2:
- Flat foot posture
- Lower medial arch
- Rear foot eversion
- Flexible flat foot
- Stage 3:
- Same as stage 2
- Extreme flat foot
- Spring ligament damage
- Hypermobility at talonavicular joint
Posterior Tibialis Exercises = ?
Clinical Syndromes
Posterior Tibialis - Exercises:
- Open Chain and Closed Chain exercises
- Focus on PTT strengthening
- Inversion strength
- Heel cord strength
- 1st MTP extension
- Hip abduction strength
- Squat with emphasis on good neutral control of the ankle without pronation.
Medial Tibial Stress
- What is it = ?
- How is it managed = ?
Clinical Syndromes
Medial Tibial Stress Syndrome:
- “Shin splints” – excessive traction on periosteum
- Posterior tibialis are common muscles contributing to this condition
- Can have tibial stress fracture
- Typically female, lower BMI, >5 cm of pain along medial distal tibia
- Often have over pronation/rapid pronation of the foot
- Increased mileage – typical in runners
- Poor running mechanics “heel strikers and poor absorption
- Diagnosis:
- Pain with exercise, posteromedial border of tibia, diffuse area of pain 5 cm’s in size or greater
- Management:
- Rest to alleviate symptoms, ankle mobilizations possible orthotics foot taping, strengthening posterior tib, gastroc/solus, foot intrinsics. Eccentric training
CECS
- What is it = ?
- Criteria for diagnosis = ?
Clinical Syndromes
Compartmental Syndrome:
- The symptoms of Chronic exertional compartment syndrome (CECS) are secondary to decreased blood flow due to increased compartment pressures.
- Seen in long distance runners and solders.
- Exact cause is unknown; Muscle hypertrophy, decreased venous return, microtrauma, myopathies and noncompliant fascia all may play a factor.
- Symptoms are severe pain and tightness worse with increasing exercise intensity and duration (insidious onset). Numbness in the leg also possible.
- Needle/catheter manometry can be used to confirm diagnosis. Patients with CECS have increased intracompartmental pressure in the affected extremity at rest and during and after exercise
- Criteria for diagnosis:
- 1) preexercise pressure ≥15 mmHg
- 2) 1-minute postexercise pressure ≥30 mmHg
- 3) 5-minute postexercise pressure ≥20 mmHg
Morton’s Neuroma
- What is it = ?
- Tests = ?
- Treatment = ?
Clinical Syndromes
Morton’s Neuroma:
- Perineural fibrosis and nerve degeneration of the common interdigital nerve usually between the 3-4th metatarsals.
- Pain paresthesia, painful clicking
- Tests
- Foot Squeeze Test
- Web Space Tenderness Test
- Treatment:
- Use a wider toe box shoe
- Steroid injection
- Unload the area, correct biomechanical faults, soft sole shoes with wide toe box
- Surgical excision of plantar nerve is common.
Hallux Valgus
- What is it = ?
- Tests = ?
- Treatment = ?
Clinical Syndromes
Hallux Valgus: Deformity of the first MTP joint; disruption of alignment more than 15 deg.
- More common in women than males.
- Subluxation of the flexor hallucis longus
- Irreversible foot deformity
- ‘Bunion’ is the common term
- No SPECIAL TESTS
- Treatment:
- Orthotics
- Larger toe box
- Strengthening intrinsic foot muscles
- Balance and global strengthening
- Possible surgery in significant cases
Hallux Rigidus/Limitus
- What is it = ?
- Test & Grades = ?
Clinical Syndromes
Hallux Rigidus / Limitus:
- Decreased DF or extension of the first ray
- Typically due to arthritic changes
- Normal = 75 deg. of DF
- Can be due to sprain of the first MPJ often referred as turf toe
- Can have spurring osteophytes and articular degeneration
- Test - Functional Hallux Limitus Test:
- Patient is NWB
- Examiners uses one hand to maintain the subtalar joint in neutral while maintaining first ray in DF.
- Moving hand DF’s proximal phalanx.
- (+) Test = Limited movement at the toe.
- Immediate PF of the first ray with DF of the proximal phalanx
- Grades:
- Grade 0: Dorsiflexion 40-60 degrees
- Grade I: 30-40 degrees of dorsiflexion
- Grade II: 10-30 degrees of dorsiflexion
- Grade III: Dorsiflexion 0-10 degrees
Hallux Rigidus/Limitus
- Treatment = ?
Clinical Syndromes
Hallux Rigidus/Limitus:
- Early treatment: protection of the joint and stresses.
- Distraction and Extension mobilizations.
- Surgical debridement to achieve 70 degrees of first ray extension.
- Rocker bottom shoe
Turf Toe
- What is it = ?
- Grades = ?
- Treatment = ?
Clinical Syndromes
Turf Toe:
- Sprain of the first MTP
- Typically seen in football, basketball and soccer players.
- Due to repetitive hyperextension of the first MTP joint
- Grades:
- Grade I – Minor stretch to the soft tissue, minimal pain and swelling.
- Grade II – Sprain or partial tear of the capsuloligamentous structure with moderate pain and swelling.
- Grade III – Sprain or complete tear of the plantar plate with severe swelling, pain, ecchymosis, and unable to bear weight
- Treatment:
- Rest
- Ice
- Compression
- Taping
- Prevent Rapid DF of the MTP
- Incorporate : Balance, strengthening exercises, flexor hallucis brevis and longus strengthening
Cuboid Syndrome
- What is it = ?
- Treatment = ?
Clinical Syndromes
Cuboid Syndrome:
- Lateral Midfoot pain w/ gradual onset
- “Subluxed” cuboid due to disruption of calcaneal cuboid ligament.
- The patient feels like they are walking with a “small pebble in shoe.”
- Treat with cuboid whip manipulation/mobilization
- Treat impairments
Metatarsalgia
- What is it = ?
- Special Test = ?
- Treatment = ?
Clinical Syndromes
Metatarsalgia:
- Pain typically in the 2nd and 3rd metatarsals
- Due to body weight being transferred during gait
- Results in stress on the 2-3rd metatarsal heads
- May start to have calluses on 2-3rd metatarsal heads.
- Patient’s have pain 2-3rd MTP with ambulation
- Special Test:
- Metatarsal/foot squeeze test
- Treatment:
- Metatarsal pads
- Orthotics to reduce load over 2-3 met heads
- Stretching of the heel cords
- Assess intertarsal mobility/DF ROM
- Adequate pronation/foot control
- Intrinsic muscle strengthening
Lis Franc Injury
- What is it = ?
- Treatment = ?
Clinical Syndromes
Lis Franc Injury:
- Ligament between first cuneiform and 2nd metatarsal disruption along with possible dislocation of mid foot from metatarsals.
- Often a plantarflexed foot with compression.
- Deformity, swelling, usually trauma, typically surgically repaired.
- Typically, a fracture dislocation
- Spacing between the first and second metatarsal is used to determine severity
- Typically, surgery is in order
Kohler’s Disease
What is it = ?
Clinical Syndromes
Kohler’s Disease:
- Osteochondrosis of the navicular
- Self limiting
- Seen in children between 2-10 y/o
- Etiology is unknown
- Disease usually resolves in 7-15 months
- Treat the impairments – typically not seen in physical therapy
Sesamoiditis
- What is it = ?
- Treatment = ?
Clinical Syndromes
Sesamoiditis:
- Avascular changes or inflammation without radiographic evidence of fracture to the sesamoid bone.
- The hallucis sesamoids are two small bones embed in the tendon of flexor halluces brevis.
- They absorb weight bearing
- Pain and tenderness under the first MTP
- Treatment:
- Decrease weight bearing
- Provide cushion under the sesamoid
- Surgery:
- To remove sesamoids but decreases joint mechanical function
Stress fractures of the foot occur due to = ?
Clinical Syndromes
Stress fractures of the foot:
- Metatarsal stress fracture
- Training overload
- Typically, more common in females
- Lower BMI and amenorrhea are risk factors
- Navicular Stress fracture
- Sesamoid stress fracture
- Usually due to an increase in training, faulty biomechanics
- Intervention: rest, ice, non-weight bearing, boot immobilization
Traumatic Fractures of the foot and ankle include = ?
4
Clinical Syndromes
Traumatic Fractures of the foot and ankle:
- Talar Dome Fractures -
- Chondral Fractures
- Pain with walking, swelling, locking and crepitus
- May present like sprained ankle
- Unimalleolar Fractures -
- Lateral malleolar fractures
- High velocity mechanism
- Bimalleollar & Trimalleolar fractures -
- Due to a severe pronation and external rotation force (similar to high ankle sprain).
- Trimalleolar involves the medial, lateral and posterior malleolus.
- Typically fix with open reduction and internal fixation.
