Foot and Ankle Flashcards
Foot and Ankle Primary Care
Diagnosis, Treatment, and When to Refer
Inside Each Foot There Are
- 26 _____
- 33 _____
- 19 _____
- 10 ____ 107 ________
- 26 bones
- 33 joints
- 19 muscles
- 10 tendons 107 ligaments
Foot Anatomy
Nail Anatomy
Diagnostic Tests for Foot, Ankle, Nail Abnormalities
(4)
Periodic Acid-Schiff (PAS) Reaction
Gomori Methenamine Silver (GMS) Stain
Fontana Masson Stain
PCR Assay (Molecular Genetic Testing)
Periodic Acid-Schiff (PAS) Reaction
Best for (1)
Most often does as (1)
- How does this test work?
- Reacts with most but not all (2)
- Sensitivity?
Best for superficial skin/nail infections, which do not disclose abundant acute inflammation
Routine Exam
- Chemical reaction, whereby carbohydrates are oxidized to form aldehydes → Aldehydes react with Schiff reagent to produce a magenta color
- Reacts with most fungi and yeast, shows excellent fungal morphology
- High sensitivity (few false negatives), but rarely organism specific
Gomori Methenamine Silver (GMS) Stain
Better for (1)
(1) Sensitivity when done with (1)
- How does it work?
- Stains most but not all (2)
- Sensitivity vs. morphology?
Better for Fungal Infections found in association with abscesses, better visualization of fungal infections in the deep tissues
High Sensitivity when done with PAS (but not organism specific)
- Stains carbohydrates (sugars), tissue is pre-treated with chromic acid, then silver is applied
- Stains most but not all fungi and yeast, may excel at staining degenerated organisms
- Offers high sensitivity, but poor morphology (target acquires a “dirty” granular appearance”
Fontana Masson Stain
Best used for (1)
Adds what to sensitivity?
- Highlights _____ pigment in fungal organisms
- Large quantities of melanin pigment favors dematiaceous ____ (pigmented saprophytic mold)
- Deciphers _____ pigment from other pigments (hemosiderin)
Validates the presence of an underlying melanocytic process, e.g. benign matrical melanotic macule, nevus, or melanoma
Adds specificity (identifies dematiaceous fungi) and screens for pigmented lesions within nail matrix
- Highlights melanin pigment in fungal organisms
- Large quantities of melanin pigment favors dematiaceous fungi (pigmented saprophytic mold)
- Deciphers melanin pigment from other pigments (hemosiderin)
PCR Assay (Molecular Genetic Testing)
What does this test do?
Sensitivity?
- If detected, g____ specific for the pathogens genus +/- species are sought
- Offers 2-3 day turn-around-time, rather than 28 days via c_____
- As a clinical lab test (such as bloodwork), molecular genetic studies are often paid for in-full by insurers
- Organism identification may be necessary for preauthorization of new topical nail antifungal products (indicated against Trichophyton Spp only)
- Augments the superior sensitivity of PAS/GMS, by providing high ______ (______ identification) for tar_____ patient therapy
Detects the genetic material of the pathologic fungi (dermatophytes, saprophytes, and/or yeasts)
Compared to culture, offers 25% higher sensitivity than culture overall, and twice its sensitivity when detecting dermatophytes
- If detected, genes specific for the pathogens genus +/- species are sought
- Offers 2-3 day turn-around-time, rather than 28 days via culture
- As a clinical lab test (such as bloodwork), molecular genetic studies are often paid for in-full by insurers
- Organism identification may be necessary for preauthorization of new topical nail antifungal products (indicated against Trichophyton Spp only)
- Augments the superior sensitivity of PAS/GMS, by providing high specificity (organism identification) for targeted patient therapy
What condition is shown in this picture?
Onychomycosis
Onychomycosis is a fungal infection of the toenails or fingernails that may involve any component of the nail unit, including the matrix, bed, or plate. Onychomycosis can cause pain, discomfort, and disfigurement and may produce serious physical and occupational limitations, as well as reducing quality of life
Mimics of Onychomycosis
What condition is shown in these pictures?
Mimics of Onychomycosis
What condition does this picture show?
Symptoms
- p____ under nail
- l_____ nail
Cause
- pressure or imp____ to toenail
- bl_____ under nail causes discoloration
Intervention
- Acute dec______ if severe pain
- Leave it _____
Subungual Hematoma
Symptoms
- pain under nail
- loose nail
Cause
- pressure or impact to toenail
- bleeding under nail causes discoloration
Intervention
- Acute decompression if severe pain
- Leave it alone
Antifungal Medications
Warts
What type of Warts are shown in these pictures?
Verruca Plantaris (left pic)
Verruca Plantaris (Mosaic) (right pic)
H&E Verruca
Treatment for Warts
Topicals/Orals
- S____ Acid
- Candida injections
- Can____
- Ret_____ Creams
- 5-__
- Bleo_____ injections
- I______therapy
- Cim_____
- Salicylic Acid
- Candida injections
- Canthrone
- Retinoid Creams
- 5-FU
- Bleomycin injections
- Immunotherapy
- Cimetidine
Treatment for Warts
Surgery/Modalities
- C____therapy
- Pulse D___ La___
- C____tage + Hyfercation
- Cryotherapy
- Pulse Dye Laser
- Curettage + Hyfercation
Mimics of Verucca
What condition is shown in this picture?
Treatment
- De_______ (frequent)
- (1) with padding or orthoses
Intractable Plantar Keratosis (IPK)
Treatment
- Debridement (frequent)
- Offloading with padding or orthoses
IPK is caused by a “dropped metatarsal,” which happens when the metatarsal head drops to a lower level than the surrounding metatarsals and protrudes from the bottom of the foot. This results in more pressure being applied in this area and causes a thick callus to form.
Inflammation of the fingers or toes in one or more of the three nail folds. Acute form is caused by polymicrobial infections after the protective nail barrier has been breached
Paronychia
Paronychia Treatment
Acute
- __ ABX
- _______ ABX
- Home S____
- Surgical De_______
Chronic
- Phenol/Al____ Chemical Matrix______
- Sur___ Matrix_____
Acute
- PO ABX
- Topical ABX
- Home Soaks
- Surgical Decompression
Chronic
- Phenol/Alcohol Chemical Matrixectomy
- Surgical Matrixectomy
Is an inflammation of the sesamoid bones in the ball of the foot and the tendons they are embedded in. It’s usually caused by overuse, especially by dancers, runners and athletes who frequently bear weight on the balls of their feet. It’s treated with rest and anti-inflammatory medication
Is a condition in which the ball of your foot becomes painful and inflamed. You might develop it if you participate in activities that involve running and jumping. There are other causes as well, including foot deformities and shoes that are too tight or too loose
Sesamoiditis
Metatarsalgia
Sesamoiditis or Metatarsalgia
-
Symptoms
- P____
- Sw_____ at ball of foot
-
Causes
- Imp____ → Inf____
- Fr______ sesamoid
-
Intervention
- Rest or Off_____
- I__
- C_______
- E_____
- P____ control
-
Symptoms
- Pain
- Swelling at ball of foot
-
Causes
- Impact → Inflammation
- Fractured sesamoid
-
Intervention
- Rest or Offloading
- Ice
- Compression
- Elevation
- Pain control
Puncture wound/Foreign Body
Foreign body may either still be present or just puncture wound
Intervention (1)
Call someone who has experience as situation may complicated
Athletes foot, fungal skin infection
White, scaling plaques in a moccasin distribution
Tinea Pedis
Tinea Pedis Treatment
- (1) for 2-4 weeks
- Add topical (1) if very itchy or pustular
- Topical antifungal cream, lotion or foam for 2-4 weeks
- Add topical steroid if very itchy or pustular
What condition is shown in these photos?
Treatment
- Topical antifungal (1)* for 2-4 weeks
- Consider adding topical (1)for bacterial infection (Rx (2) 1% pledgets)
- Topical antifungal GEL for 2-4 weeks
- Consider adding topical ABX for bacterial infection (Erythromycin or Clindamycin 1% pledgets)
A superficial infection of the skin caused by Corynebacterium minutissimum, a gram-positive, non-spore-forming bacillus. The disorder typically presents as macerated, scaly plaques between the toes or erythematous to brown patches or thin plaques in intertriginous areas
Erythrasma/Corynebacteria
A bony bump that forms on the MTPJ (metatarsophalangeal) joint at the base of the big toe, caused by tight shoes, foot stress, arthritis
Hallux Valgus
Hallux Valgus Treatment
Conservative
- W____ shoes
- P__dings
- St___ping
Surgical
- B_____ectomy
- O___ctomy
- O____tomy
- Fus___
Conservative
- Wider shoes
- Paddings
- Strapping
Surgical
- Bunionectomy
- Ostectomy
- Osteotomy
- Fusion
Common type of arthritis that causes a “stiff big toe”
Hallux Rigidus/Limitus ROM
Hallux Rigidus/Limitus ROM Treatment
Conservative
- _____-bottom shoes
- Injections
- Orth_____
Surgical
- Ch____ectomy
- Impl_____
- F______
Conservative
- Rocker-bottom shoes
- Injections
- Orthotics
Surgical
- Cheilectomy
- Implants
- Fusion
Blisters
Symptoms
- P____
Causes
- Fr_____
- Improper ____
Intervention
- a) leave _____
- b) clean it, ___ it, cover it
Symptoms
- Pain
Causes
- Friction
- Improper shoes
Intervention
- a) leave alone
- b) clean it, pop it, cover it
Foot Trauma
5th metatarsal fracture (shaft or avulsion)
(2)
- Symptomatic treatment (_____ bearing vs. ___ Weight Bearing)
- ____ walker or post-op shoe
Jones Fracture
Stress Fractures
- Symptomatic treatment (Weight bearing vs. Non Weight Bearing)
- Cam walker or post-op shoe
Jones Fracture
=
- Delayed or non-union significant complication
- Treat in c___, (1) bearing 6 weeks
- O____ for athlete or healthy active patient
Fracture at Base of 5th metatarsal
- Delayed or non-union significant complication
- Treat in cast, non-weight bearing 6 weeks
- ORIF for athlete or healthy active patient
Stress Fractures
- Rate of microfracture _____ rate of repair
- M________, calcaneus, tibia, fibula
- Often not _____ on initial films (delayed approximately 2 weeks), positive bone scan
- Generally _____ tender on exam
- Rule out pathologic process
- Usually 2° sudden increase in activity
- Treatment (2)
Peroneal Tendon Injuries
Tendon t___
Tendon_____
Sub_____ peroneal tendons/Peroneus _____ Pathology
Tendon tears
Tendonitis
Subluxing peroneal tendons/Peroneus Brevis Pathology
Ankle Sprains
Physical Exam
- P____
- Lateral collateral ligaments of ankle
- Deep to ankle joint
- Lateral malleolus
- Compression of tibia and fibula
- Ed_____
- Ec_________
- Jump/Hop Test =
- Pain
- Lateral collateral ligaments of ankle
- Deep to ankle joint
- Lateral malleolus
- Compression of tibia and fibula
- Edema
- Ecchymosis
- Jump/Hop Test = In this test, the aim is to jump as far as possible on a single leg, without losing balance and landing firmly. The distance is measured from the start line to the heel of the landing leg. The goal is to have a less than 10% difference in hop distance between the injured limb and uninjured limb
Ankle Rules for Radiography
An ankle x-ray is only required if
Treatment for Grade 1 Ankle Sprain
(1) + (1)
RICE + NSAIDs
Treatment for Grade II Ankle Sprains
(1) + (1)
(1)
(1) with brace or CAM boot
RICE + NSAIDs
Time
Immobilization (brace or CAM boot)
Treatment for Grade III Ankle Sprain
(1) + (1)
More (1)
(1) (CAM boot or plint)
(1)
RICE + NSAIDs
More time
Immobilization (CAM boot or splint)
NWB
Ankle Stability Exam
(2)
Anterior Drawer
Talar TIlt
Chronic Lateral Ankle Instability Treatment
Physical Therapy
- Start ~__ weeks after injury
- Str_______ exercises
- Pro_______ exercises
Ankle Sprain Rehabilitation Exercises
- _______ stretching
- Standing c____ stretch
- Standing s_____ stretch
- Active (1)
- Resisted ankle _________
- Reisted ankle plantar _______
Ankle ____ing and ____ing
Physical Therapy
- Start ~3 weeks after injury
- Strengthening exercises
- Proprioception exercises
Ankle Sprain Rehabilitation Exercises
- Towel stretching
- Standing calf stretch
- Standing soleus stretch
- Active ROM
- Resisted ankle dorsiflexion
- Resisted ankle plantar flexion
Ankle bracing and wrapping
Common problem when the posterior tibial tendon becomes inflamed or torn
Posterior Tibial Tendon
Physical Exam Signs for Posterior Tibial Tendon
(2)
“Too Many Toes” Sign
Single Heel Rise
Imaging for Posterior Tibial Tendon
(2)
Xray
MRI
Posterior Tibial Tendon Dysfunction (PTTD) Grading
Posterior Tibial Tendon Dysfunction (PTTD) Treatment
- (1) + (1)
- ____loading
- Orth____
- Custom Br_____
- S______
- RICE + NSAIDs
- Offloading
- Orthotics
- Custom Bracing
- Surgery
Surgery for Posterior Tibial Tendon Dysfunction
(1)
The PTT connects to the navicular bone near the middle of the foot at the instep. In this surgery, your foot and ankle orthopaedic surgeon will remove the Flexor digitorum longus (FDL) tendon from its usual position and transfer it to the navicular bone. This helps support or replace the diseased PTT to improve function. The diseased PTT is cleaned up or removed to eliminate it as a source of pain.
FDL Tendon Transfer to PTT
Calcaneal Osteotomy with Lateral Column Lengthening and PTT Reconstruction
Describe this surgery?
A calcaneal osteotomy is a controlled break of the heel bone to correct a deformity of the foot and ankle
Swelling and Pain at Ball of Foot with Weightbearing
Physical Exam
Match each picture with each Condition
- Pain at plantar metatarsal heads =
- Elevated toe =
- Skin lesions plantar =
- Pain with foot lateral and interspace compression =
- Pain over dorsal metatarsal neck/shaft =
- Pain at plantar metatarsal heads (1st pic)
- Elevated toe (5th pic)
- Skin lesions plantar (2nd pic)
- Pain with foot lateral and interspace compression (4th pic)
- Pain over dorsal metatarsal neck/shaft (3rd pic)
What Conditions are shown in these X-rays?
What conditions are shown in these images?
Morton’s Neuroma
What condition does this image show?
Plantar Plate Tear
Metatarsalgia Treatment
- R____ + N_____
- _____ Splint (top left pic)
- Custom ______(bottom left pic)
- ______ (right pic)
- RICE + NSAIDs
- Budin Splint (top left pic)
- Custom Orthotics (bottom left pic)
- Surgery (right pic)
Morton’s Neuroma Treatment
- Activity/Shoe mod______
- Custom ______
- N_____s + Rx (1)
- St_____ Injection
- Al_____ Sclerosing Injection
- Surgery: (1)
- Activity/Shoe modification
- Custom Orthotics
- NSAIDs + Gabapentin
- Steroid Injection
- Alcohol Sclerosing Injection
- Surgery: Neurectomy
Plantar Plate Tear Treatment
(2)
Strapping
Surgery
Plantar Fasciitis
Acute overuse injury with (2) distinct components
Both need to be addressed for successful outcomes
MSK: tight posterior muscle group
Inflammatory: inflammation from microtears of fascia
(1)
The mechanics of the foot, II: the plantar aponeurosis and the arch
The Truss
The plantar aponeurosis, also known as the plantar fascia, is a strong layer of white fibrous tissue located beneath the skin on the sole of the foot.
(1)
Refers to the function of the anatomy on the base of the foot, specifically the plantar aponeurosis, sesamoid bones, plantar pads and the attachment of these structures under the MTPJ.
Windlass Mechanism
Pathomechanics of Plantar Fasciitis
- _____ works unopposed when sleeping or at rest → ______
- With _____ , the forefoot and hindfoot are opposed → _____ mechanism initiated → ______ of the fascia at its insertion causing ________
- Achilles works unopposed when sleeping or at rest → shortens
- With propulsion, the forefoot and hindfoot are opposed → Windlass mechanism initiated → microtearing of the fascia at its insertion causing inflammation
Overpronation
Excessive mobility → increase the level of stresses applied to the fascia → plantar fascial elongation → increased tissue stress
Overpronation
Imaging XR
Traction phenomenon on plantar fascia due to tightness → heel _____
Plantar heel spurs are a radiographic finding and DO ___ HURT. They are ___ the cause of fasciitis
Traction phenomenon on plantar fascia due to tightness → heel spur
Plantar heel spurs are a radiographic finding and DO NOT HURT. They are NOT the cause of fasciitis
PHASE I: Fasciitis Treatment
Expectation is improvement >___% within __ weeks along all points of protocol
Expectation is improvement >50% within 3 weeks along all points of protocol
Home PT Stretches and Night Splint for Plantar Fasciitis
Custom Orthotics for Plantar Fasciitis
- Captures the foot in subtalar joint _____
- Directly reduces st____ on fascia
- Elevates ____ → reduces Achilles effect on fascia
- Added cush______ if heavy heel striker
Corticosteroid Injection
- Topical Refrigerant
- ____ chloride
- 2.5 cc steroid cocktail
- 1cc Marcaine 0.5%
- 1cc D______ 4mg
- 0.5cc K_____ 40
- Approach ______
- Aim for plantar medial tubercle of calcaneus
- Wait __ minutes for response
Conclusion: steroid injection showed a clear benefit over placebo at __ weeks and this difference was maintained at __ weeks
- Topical Refrigerant
- Ethyl chloride
- 2.5 cc steroid cocktail
- 1cc Marcaine 0.5%
- 1cc Dexamethasone 4mg
- 0.5cc Kenalog 40
- Approach medially
- Aim for plantar medial tubercle of calcaneus
- Wait 5 minutes for response
Conclusion: steroid injection showed a clear benefit over placebo at 6 weeks and this difference was maintained at 12 weeks
Phase II: Fasciitis Treatment
__ weeks after initial visit with __
Expectation is improvement >__% within 3 weeks along all points of protocol
3 weeks after initial visit with <50% improvement in VAS (visual analog scale (pain scale))
Expectation is improvement >50% within 3 weeks along all points of protocol
Phase IV: Fasciitis Treatment
(1) Findings of moderate to severe fasciitis
OR
Plantar Fasc_____
OR
Recalcitrant ____ pain x3 months with appropriate therapies
MRI Findings of moderate to severe fasciitis
OR
Plantar Fasciosis
OR
Recalcitrant heel pain x3 months with appropriate therapies
PRP + Plantar Fasciosis
- ___ conservative tx or cortisone injection within __ days
- 7/9 pts ______ resolution of pain at 1 year
- 9/9 patients had improvement noted on diagnostic ____
- No conservative tx or cortisone injection within 90 days
- 7/9 pts complete resolution of pain at 1 year
- 9/9 patients had improvement noted on diagnostic U/S
Extracorporeal Shock Wave Theory for treatment of Chronic Plantar Fasciitis
- ______waves create a “new _____”
- Br____ scar tissue
- F____blast stimulation
- An______ (?)
- 65-85% success rate in reported literature, however, not all studies show statistical improvement
- Soundwaves create a “new wound”
- Breaks scar tissue
- Fibroblast stimulation
- Analgesia (?)
- 65-85% success rate in reported literature, however, not all studies show statistical improvement
What treatment for plantar fasciitis is shown in these photos?
Tenex Microtenotomy and Debridement
Phase V: Plantar Fasciitis/osis
When all else fails..Plantar (1)*
- Risk of Open = ____ plantar nerve injury
- Risk of Endoscopic = lateral ____ overload, _____ nerve injury
When all else fails..Plantar Fasciotomy*
- Risk of Open = medial plantar nerve injury
- Risk of Endoscopic = lateral column overload, calcaneal nerve injury
A chronic, non inflammatory disease with vascular and cellular changes that result in loss of the biomechanical and elastic properties of the tendon tissue
Tendinosis
Extracorporeal Shockwave Therapy for the Treatment of Achilles Tendinopathies
Is ESWT effective in tendinopathies?
Extracorporeal shockwave therapy has been shown to be effective in the treatment of chronic tendon pathology in the elbow, shoulder, and plantar fascia.
Radiofrequency Coblation (Topaz) for chronic tendinosis
Bipolar RF micro______ performed via “cold abl______” of tissue
Bipolar RF microtenotomy performed via “cold ablation” of tissue
This procedure is done by inserting a needle (or needles) through the skin to reach diseased tendons. The surgeon uses ultrasound to see the tissues and find the affected tendon(s). The needles are used to remove the diseased tissues. They also stimulate the surrounding healthy tissues to encourage the healing process.
Chronic Tendon Disease
What condition is shown in this picture?
Achilles Tendinosis
Chronic Tendon Disease
What condition is shown in this picture?
Plantar Fasciitis/Fasciosis
