FF summary Flashcards
Metatarsalgia
Physical exam
Pain on palpation- met heads
Little or no inflam (rare= bursitis)
Metatarsalgia
Pathogenesis
Inc pronation
Dec tran. Arc
Metatarsalgia
Diagnosis
Rule out everything else
Metatarsalgia
Treatment
Rest ,ice
Met pads
Orthotics
Pain meds
Nerve injury
Compression
- Neuropraxia- most common
Distal- TIPS compression (casting, shoes)
Prox- herniated disc
Reversible ischemia
Transient dec sensation(d-w): dec conduction until remyelination
Nerve injury
Compression
2. Axonotmesis-severe/crush Demyelination= dec sensation (wks-m) Intact basement membrane Axon regeneration, remyelination Really severe? Wallerian degen (perm loss)
Nerve injury
Transection
Neurotmesis (least common)
- laceration
- no basemembrane
Nerve injury
Ischemia/ infarct
Caused by vasculitis/ atherosclerosis
Conduction not decreased
Basement membrane intact= can regen , sciatic n most common,
Peroneal/ tibial too
Nerve injury
Radiation-induced
Seen w radiation treatment
Delayed presentation
Dec sensation, proprioception
Weakness
Nerve injury
Degeneration (most common cause of injury)
Distal: distal->prox deg /longest n first
Most vuln to metabolic/toxic activity
Nerve injury
Inflammation
Infections- EBV, HSV, Zoster(most common)
Diabetes- radiculopathy (most common)
Sjogrens(dorsal root ganglion)
Nerve injury
Common symptom
Pain, paresthesia, anesthesia,
Pruritis(itching)
Motor function loss
Nerve injury
Autonomic inv
Skin changes due to nn injury
Slow wound healing due to poor innervation to sm mm
Nerve injury
Physical exam
Valleix- prox+dis
Tinel- distal
Tingling and pain
Common n entraps
Morton
McDonald
Common dig n
Joplin
Med proper dig n to hallux (1st)
Ant tarsal tunnel
Deep fib n
Lemonts
Superficial fib n
Tarsal tunnel syndrome
Post tib n
Compressed common dig n
Morton’s neuroma
Most common:3rd interspace than 2nd (largest)
F>M; shoe choices
Morton’s neuroma
Morton’s neuroma
Etiology
Compressed by DTIL ( or by bursa from trauma)
Morton’s neuroma
Symptoms
Pain, burning, tingling
Pebble in shoe (worse wt bearing)
Morton’s neuroma
Diagnosis
Dec sensation adjacent toes Mulder's sign Pencil test DF= pain Sullivan's sign (splayed toes near neuroma on x ray) Lidocaine injection
Ultrasound is best!
Morton’s neuroma
Differential
Friedberg RA Callus Bursitis Tarsal tunnel, tumor
Entrapment neuropathy of plantar proper digital n to hallux( due to trauma from shoe gear)
Associate w HAV
Joplin’s neuroma
Joplin’s neuroma
Treatment
Orthotics, pedding, taping
Injections
- corticosteroids: avoid acetate = avoid fat atrophy
- sclerosing alcohol(hardening n): 7-10, 1-2wks apart
Surgical removal, or cut DTIL
Joplin’s neuroma
Complication
Comes back-stump neuroma
CRPS- symp pain msg doesnt turn off
Digital deformity- lumbrical, interossei mremoved=claw/hammer toes
Nerve entrapment
Ant. Tarsal tunnel (deep peroneal n)
Pain at ant ankle
Dec sensation 1st interrspace
*physical exam
Lag time to distal mm
Abnormal extensor digitorum brevis m
Nerve entrapment
Lemont (superficial peroneal n, INTERME, MEDIAL dorsal cutaneus n)
Tight shoes
Nerve entrapment
Sural n
Int compress- peroneal tendon path, lipomas, cysts
Ext compress- shoe pressure
Trapped at 5th met and CC joint
Nerve entrapment
Common fibular n
Compressed at
- peroneal longus m belly
- neck of fibula
Ext pressure: casts, long surgery, crossing legs, squatting
Lead foot drop(-> steppage gait), dec sensation,
Treatment: remove compression, AFO, PT
Ant tarsal tunnel
Diagnostic testing
EMG, NCS, NCV MRI CT Serologic- HbA1C, lyme titers LP- unusual
Lemont
Diagnostic testing
EMG, NCS, NCV MRI CT Serologic- HbA1C, lyme titers LP- unusual
Sural n
Diagnostic testing
EMG, NCS, NCV MRI CT Serologic- HbA1C, lyme titers LP- unusual
Only a little broken
Metatarsal stress fracture
2nd met most common
Metatarsal stress fracture
Normal bone w inc pressures
Stress/fatigue
Metatarsal stress fracture
Normal pressure w weak bone
Insufficiency
Metatarsal stress fracture
Metatarsal stress fracture
Wolf law
March fracture- military
Metatarsal stress fracture
Risk factors-anatomic
Biomechanically related
Metatarsal stress fracture
Risk factors-physiologically
Age, wt, osteopenia
Metatarsal stress fracture
Risk factors- external
(5th met non-union due to disrupted nutrient a)
Shoes, training intensity or surface, post-op
Metatarsal stress fracture
Symptoms
Sharp pain, pain on palpation w wt
-> get x ray/MRI
Metatarsal stress fracture
Treatment
RICE + restrict activity
Surgical shoes/ supportive shoes
Incomplete fracture leading to avasculaization w necrosis
See osteochondritis of 2,3,4 th met heads
Flat, widen
Frieberg’s infarction
F>m
Occurs after 11-13 yrs
Frieberg’s infarction
Frieberg’s infarction
Presentation
Dull/aching FF -> worse at end ROM (w wt bearing)
Subchondral fracture, resorption of necrotic bone
Frieberg’s infarction
Treatment
Early- immobilize
Late- met bar/ pad
NSAIDs
Surgery if doesnt work
Inflamed sesamoid apparatus
Sesamoiditis
Sesamoiditis
Symptoms
Insidious- worse w activity
Mild ache -> throbbing
Local edema sometimes
Sesamoiditis
Examination
Pain on palpation
Hallux DF= worse
Xray rule out fracture
Sesamoiditis
Treatment
Dancer’s pad(cut out at 1st met head)
NSAIDs, BK Fiberglass cast, corticosteroid inj, surgery
Swelling, bruising
Sesamoid fracture
Sesamoid fracture
X rays
AP, MO, FFA
25% bipartite; 85% b/l
Bipartite, 2 pieces together larger than other sesamoid
NSAIDS
BK casting > 8wks
Hallux limitus/rigidus
Types
(Normal- DF 1st MPJ 65)
- structural: dec 1st MPJ in gen
- func: dec ROM w closed -normal w open
Hallux limitus/rigidus
Symptoms
Discomfort-> pain, immobility, joint destruction,
Hallux limitus/rigidus
Etiology
I SO GOT
-structural: met primus elevatus, long/short 1st ray, hypermobile 1st ray
- trauma
- surgical complication
- gout, OA
- infection
- osteochondritis dessicans
Hallux limitus/rigidus
Radiograph (think OA)
Dec joint space
Subchon sclerosis , cysts
Osteophyte
Joint mouse-> detached osteophyte
Hallux limitus/rigidus
Treatment
Padding
Stiff sole
Morton’s extension
Surgery( joint fusion)
Digital deformities
Hammertoes (E-F-E)
Causes
- Flexor stabilization (most common): late stance
Pronated foot
AductoVarus 4,5th- loss mech adv of quad plantae
Asso w weak interossei mm
Treatment: artheroplasty
Digital deformities
Hammertoes (E-F-E)
Causes
- Flexor substitute (least common): late stance
Supinated foot type
Flexors> triceps surae m
Treatment: arthrodesis, tendon transfer
Digital deformities
Hammertoes (E-F-E)
Causes
- Extensor substitution: swing
Ext> lumbricals
MPJ ext >90: due to pes cavus, ankle equinus, lumbrical weak, TA weak, EDL splasticity & pain
Treatment: arthrodesis
Hammertoes (E-F-E)
Etiology
Idiopathic Inc PF mets Shoe p Intrinsic m imbalance L/S ext dysfunction MPJ instability from inc fluid (injection) Loss of FHB 2ndary to HAV
Claw toe
E-F F
Mallet toe
DIP = F
Etiology= imbalance mm
Adductovarus digital rotation
Severity=5>4>3
Etiology= pronated foot-> abd twist-> dist ph pull med/post
Pathology= HI BUS
(Heloma dura, infection, bursa, ulcer, submet pain)
Lesions
HT- PIP, TUFT, SUBMET H
CT- PIP, DIP, TUFT, SUBMET H
MT- DIP, TUFT
ADDUCTOVARUS- (5th)PIP, (4th)DIGIT, WEBSPACE
Treatment- palliative, surgical
Painful FF
Metatarsalgia
