Foot and Ankle Flashcards
Forefoot
metatarsals through phalanges
5 rays
Midfoot
Navicular
Cuboid
Cuneiform (medial, intermediate & lateral)
Hindfoot
Talus
Calcaneus
Ankle problems - in general
Sprains Fx Achilles tendonitis Peroneal tendonitis Osteochondral lesion Subtalar synovitis Ankle arthritis - OA, RA Tarsal tunnel
Hindfoot problems - in general
Plantar fasciitis
Haglund deformity
Poster tibial dysfuction
Midfoot problems
Plantar fasciitis
Plantar fibromas
OA
Forefoot problems
Jones fx Stress fx Metatarsal fxs Metatasalgia Interdigital neuroma Hallux rigitdus Hallux valgus Hammertoe Clawtoes Ingrown toenails
Hx - in general
DETAILS!!! Onset of injury/pain MOI Duration of symptoms Affected on ADLs Past trauma / sxs Chronic illness Employment Exercise Weight Age/gender
PE - in general
Inspection / observation Neurovascular status ROM Palpation Ligament stability Muscle strength Proprioception
Ankle Sprains - Epidemiology
Most common sports injury (40%)
10% of ALL ER visits
40-50% of pts have long term sequelae
Ankle Sprains - Grading
I - no instability
II - Mild laxity of ligaments
III - Severe laxity, rupture of calcaneofibular and anterior talofibular ligaments
Ankle Sprains - General
Most involve the lateral ligament complexes as results of plantar flexion and inversion
Ankle sprain - hx
MOI
Audible pop
Swelling
Decreased function
Ankle sprain - PE (in general)
Observation Bruising Edema Palpate to localize pain ROM Muscle strength Proprioception Ligamentous stability testing Deltoid Ligament stability Test integrity of tibiofibular syndesmosis
Ankle sprain - Palpate to Localize Pain
Bony vs. ligamentous Ligaments - Lateral complex - Medial complex Bony Landmarks - Medial and lateral malleoli -Base and shaft of 5th metatarsal Proximal fibula
Ankle Sprain - ROM
Functional
- 10° dorsiflexion
- 25° plantar flexion
Ankle Sprain - Ligamentous stability testing
Anterior talofibular ligament - Anterior Drawer
Talar tilt test
Deltoid Ligament stability
Anterior Drawer Test
Pt sitting with knee flexed to 90°
Stabilize tibia with one hand
Grip calcaneus and talus anteriorly while pushing tibia posteriorly
With significant ligament injury, there will be a feeling of laxity or subluxation
- Translation of 5mm more than contralateral side is a positive test
Talar Tilt Test
Tests stability of calcaneofibular and anterior talofibular ligaments
Place inversion strss on the heel with foot in plantar flexion
- Tests stability of the ATF ligament
Place inversion stress on the heel with foot in neutral of dosriflexion
- Tests stability of calcaneofibular ligament
Deltoid ligament stability
Stabilize pt’s leg around the tibia and calcaneus and evert the foot
Gross gapping at the mortise indicates torn deltoid ligament
Test integrity of tibiofibular syndesmosis
Squeeze Test
External rotation test
Squeeze test
With pt sitting on exam table legs dangling over the edge, foot is placed in dorsiflextion
Place one hand on the pt’s tibia and the other on their fibula (close to the ankle)
Squeeze the tow leg bones together, straining the ligaments of the ankle.
The test is positive if he or she feels pain over the space between the bones
External rotation test
Place ankle in dorsiflexion and externally rotate foot
Ankle Sprain imaging
Ottawa Ankle Rules
Determine the need for x-rays in pts with an ankle injury
Pain in malleolar zone and any one of the following
- Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
- Bone tenderness along the distal 6 cm of the posterio edge of the tibia or tip of the medial malleolus
- Inability to bear weight for 4 steps both immediately and in the ED
Ankle Sprain - Tx Phase I
RICE
Function ankle brace or stirrup
Weight bearing as tolerated and crutches as needed
NSAIDs
Ankle sprain - Tx Phase II and III
Rehab (2-8 weeks post injury)
Increase ROM and improve strength
Followed by proprioception, agility and endurance training
Ankle Sprain - Tx sx
Sx tx of the acute ligamentous injury is indicated only for the occasional elite athlete
Most ligamentous injuries will heal sufficiently with no significant disability
Less severe ankle sprains may cause chronic pain or functional instability if not tx conservatively
Chronic Ankle Instability - Tx
Non-operative
- PT
- Orthotic devices
- External stabilization
Operative Tx
- Reserved only for those who have failed conservative tx and have persistent symptoms
MOI of Ankle fx
Inversion
Eversion
Outward Rotation
Stable Ankle fx
Involve one side of the joint
Fx of distal fibula w/o injury to deltoid ligaments
Unstable ankle fx
Include both side of the ankle joint
Bimalleolar or trimalleolar
Trimalleolar includes posterior malleolus of the tibia
Ankle fx - PE (in general)
Inspection
Palpation
Ankle fx - Inspection
Deformity - External rotation or lateral displacement of foot Eccymosis Edema Laceration
Ankle fx - Palpation
Pain / tenderness
- Palpable gap
Deformity
Neurovascular status
Ankle fx - Imaging
X-rays
- AP
- Lateral
- Mortise views
Types of Ankle fx
Avulsion fx
Bimalleolar fx
Trimalleolar fx
Open Fx
Ankle fx - Optimal tx criteria
- Dislocations and fxs should be reduced ASAP
- Splint with joint in most normal position
- If fx is open, give abx and take to OR for emergent irrigation and debridement - All joint surfaces must be precisely restored
- Fx must be held in a reduced position during bony healing
- Joint motion should begin as early as possible
Ankle fx - Tx of stable fx of distal fibula
Weight bearing cast or pneumatic walker for 4-6 weeks
Ankle fx - Tx of unstable fx
REFER TO ORTHO
Unstable, non-displaced fx - non-weight bearing cast for 6-8 weeks
Unstable, displaced fx
- Closed reduction or ORIF
- ORIF provides better restoration of the joint function
- Always check for widening of the ankle joint due to syndesmotic rupture
Ankle fx - Tx of open fx
Sx for irrigation and debridement and ORIF
Ankle fx - sx tx standard of care
ORIF
Immobilization for 6 weeks
Then weight bearing slowly advanced
PT for ROM, strength and ankle proprioception
Post Ankle Fx Tx Sequelae
Post-traumatic arthritis
Post-traumatic arthritis - Joints affected
Tibiotalar (ankle) Talonavicular Subtalar Calcaneocuboid Tarsometatarsal
Clinical Presentation of Post-traumatic arthritis
Pain - worsened by standing or walking
Decreased ROM
Stiffness
PE of Post-traumatic arthritis
Pain to palpation over affected joint
Joint deformity
Loss of motion
Swelling
Dx imaging of Post-traumatic arthritis and findings
X-rays - weight bearing
- AP
- Lateral
- Oblique
Findings
- Joint space narrowing
- Osteophytes
Tx for Post-traumatic arthritis
Shoe Modifications Orthotics - Foot - AFO NSAIDs Steroid injections Sx - Arthrodesis
Achilles Tendon Rupture - Epidemiology
30-50 yo male, recreational athlete (weekend warrior) Steroid use Fluoroquinolones Gout Arteriosclerosis Renal insufficiency Hyperthyroid
Achilles Tendon Rupture - MOI
Mechanical overload from eccentric contraction of gastrocsoleus complex
Sudden, forceful dorsiflexion of foot as the gastrosoleus in contraction
Achilles Tendon Rupture - Hx and PE
Pt report of hearing or feeling a "pop" Difficulty with ambulation Weakness with pushoff Swelling with palpable defect in Achilles Tendon Ecchymosis Thompson test - dx
Achilles Tendon Rupture - dx imaging
MRI is extremely sensitive, but rarely needed
Hx & PE are usually dx
Achilles Tendon Rupture - tx
REFER TO ORTHO
Non-operative tx
- serial casting of the lower leg with the ankle in plantar flexion
Sx tx
- Repair the Achilles Tendon
- Potential for wound healing problems
- Also requires serial casting with gradual progression to weight bearing
- PT for 6-12 weeks
Posterior Tibial Tendon Dysfunction - Epidemiology
Overweight
Female
>50 yo
Primary cause of medial ankle pain in middle aged pts
Posterior Tibial Tendon Dysfunction - MOI
Tendon becomes thickened and degenerates over time
Posterior tibial tendon is one of the main supporting structures of the medial ankle and arch
Function is lost and an acquired pes planus ensues
Posterior Tibial Tendon Dysfunction - PE
Pain and swelling on the inside of the ankle
Loss of arch and ankle “rolls in” - medial arch decreased or flattened
Initially pain medially but eventually moves laterally as fibula impinges
Muscle weakness
Cannot do heel raise on affected side
Posterior Tibial Tendon Dysfunction - Dx Imaging & Findings
Weight-bearing AP and lateral x-rays
Findings - sagging of talonavicular and naviculocuneiform joints
Posterior Tibial Tendon Dysfunction - Tx Acute
NSAIDs
Immobilization (short leg cast or pneumatic walker)
Activity Modification
Posterior Tibial Tendon Dysfunction - Chronic tx
Orthotics Sx - Debridement of tendon - Tendon transfer and realignment osteotomy - Arthrodesis
Plantar Fasciitis - General
Inflammation of the plantar fascia, usually near the insertion of the fascia on the calcaneus Probably secondary to repetitive strain Common condition Bil heels may be affected W>M, 2:1
Plantar Fasciitis - Hx
Pain directly beneath the calcaneus
May be along the arch
Usually worse with the first steps in the morning or period of inactivity
Plantar Fasciitis - PE
Point tenderness just anterior to calcaneus
Pain with dorsiflexion of toes and ankle
Plantar Fasciitis - Dx imaging
Not generally necessary
Weight-bearing lateral needed if proceeding with steroid injection
Plantar Fasciitis - Tx
Tx s/s Ice Heel lift NSAIDs Activity/exercise modification Stretching / PT Night splints Steroid injections Short leg walking cast for 6 weeks is beneficial in some case Refer to ortho if pt fails conservative tx (for sx)
Lisfranc Dislocation - In General
Traumatic disruption of tarsometatarsal joints
Results from significant trauma or indirectly from athletic injury - typically an axial load on a plantar flex foot
Second metatarsal and intermediate cuneiform joint is crucial in maintaining the stability of the tarsalmetatarsal joints
Lisfranc Dislocation - PE
Pain - over the tarsalmetatarsal joint
Edema - substantial
Malalignment - medial border of the second and fourth metatarsals should align with the medial borders of the middle cuneiform and the cuboid
Soft tissue damage - open wounds; vascular impairment; blistering
Lisfranc Dislocation - dx imaging
x-ray
- Lateral
- AP - medial aspect of the middle cuneiform should align with the medial border of the second metatarsal
- Oblique - medial aspect of fourth metatarsal should align with the medial border of the cuboid
May need weight bearing images for subtle injuries
May need comparison views
May see an avulsion fx
Any widening >2 mm is significant
Lisfranc Dislocation - Tx
REFER TO ORTHO Non-displaced - Immobilize - Non-weight bearing for 6-8 weeks - Rigid arch support for 3 months Displaced - Closed reduction ASAP - ORIF often required - Post-op immobilized and non-weight bearing for weeks, then slow progression Remove hardware - 4 months post-op
Charcot Foot - in general
Neuropathic, neurotrophic, or neutroarthropathic joint
DM - leading cause
Charcot Foot - characterized by
Destruction of joint surfaces
Fx with accompanied dislocations of one or more joints with an inappropriate pain response
Charcot Foot - requirements
Active pt with neuropathy and adequate blood supply
Charcot Foot - Stages
I
- Acute inflammatory phase characterized by swelling, erythema, and increased warmth
- Radiographs reveal fx and dislocations
- MUST R/O INFECTIONS
2 - Signs of healing, less swelling, warmth and ex-ray shows new bone formation
3
- Chronic phase with consolidation and resolution of inflammation and creation of rocker bottom
- Arch collapses, hindfoot and ankle with risk of collapse into varus or valgus
- increased risk of ulcer formation
Charcot Foot - tx
Refer to Ortho
Non-sx tx
- Stages 1 & 2 - immbolization splint, brace, orthosis or cast (weigh-bearing is debatable)
- Stage 3 - AFO or other accommodative footwear (rocker-bottom shoe)
Sx tx
- Early stages - ORIF & fusion
- Later stages - realignment osteotomy, fusion or removal of bone prominence
Charcot Foot - goals of tx
Limit destruction of joint
Preserve stable plantigrade foot that protects soft tissues and prevents ulceration
Jone Fx - in general
Fx of the metaphyseal-diaphyseal junction of the 5th metatarsal
Occur acutely or superimposed on chronic stress injurey
Swelling and pain on weight bearing
Jone Fx - tx
Non-operative tx is usually appropriate
- Strict non weight bearing for 6-8 weeks, b/c non-union can occur
- Walking boot for additional 2-4 week
- Sx is indicated for those who fail conservative tx or in athletes
March fx - AKA
Fatigue fx
Stress fx
Insufficiency fx
March fx - in general
Fx of the distal 1/3 of the metatarsal
Occurs due to repetive stressing
Occur when damage from a cylindrical loading of a bone overwhelms its physiologic repair capacity
Common in young active adults - women more prone to this injury regardless of age
Generally no hx of injury
March fx - Hx
Initially complains of pain of varying degree
Pain is usually present at rest but aggravated with walking
March fx - PE
Swelling and point tenderness over metatarsal
March fx - dx imaging
X-rays
- AP, lateral, oblique
- Findings vary depending on stage in the process
- May be normal or periosteal reaction or show and incomplete fx or complete fx
Bone scan, CT, MRI - occult fx
March fx - tx
Protection with short leg cast, post-op shoe or walking boot
Weight-bearing restricted until restoration of bone continuity and decreased pain - usually 3-4 week
Metatarsal fx - in general
Fx of the shaft, neck or head
Often caused by direct crushing or indirect twisting injury to the foot
Metatarsal fx - clinical features
Metatarsal shaft fx
- Temporary disability (unless failure of healing)
- Displacement is rare (non-fx metatarsals serve as an internal splint)
Metatarsal head and neck fx - Dorsal angulation is common and should be reduced
Metatarsal fx - tx of metatarsal shaft fx
Non-displaced
- hard-soled shoe with partial weight bearing or short leg walking boot
Displaced
- Reduce and cast
Persistent displacement may require ORIF
Metatarsal fx - Tx of Metatarsal head/neck fx
Usually heal w/o intervention
ORIF is controversial
Clost reduction with K wire placement under fluoro
Multiple metatarsal fx or those with >4mm of displacement need tx
Metatarsalgia - in general
General term for pain arising from the metatarsal head region
Variety of abnorms may be responsible
- High arch
- improper shoe selection
- tight Achilles tendon
- abnorm foot posture
- atrophy of plantar fat pad
- Frequently associated with hammertoes, clawed toes and hallux valgus deformities
Metatarsalgia - contributing factors
Tight toe muscles
Weak toe muscles
Hypermobile first foot bone (when joints move easily beyond the normal range expected fro that particular joint)
Tight Achilles tendon
Loose or tight footwear
High or unusual levels of physical activity
Hammertoe deformity
Excessive side-to-side movements when walking
Metatarsalgia - hx
S/S
-burning or cramping sensation in the region of the metatarsal heads, usually 2, 3 and 4
Worse with activity and relieved by rest
Metatarsalgia - PE
Alignment of toes Swelling ROM Stability of MTP joints Palpate for swelling or masses Note callous formation
Metatarsalgia - dx imaging
X-rays - weight bearing
- AP
- Lateral
Assess metatarsal and toe alignment
Metatarsalgia - tx
Transfer weight-bearing away fro affected metatarsal heads
Low-heeled shoes with sufficient room in the forefoot
Metatarsal bar or pads placed in shoe behind the metatarsal heads to transfer weight behind the metatarsal heads
Morton’s neuroma - in general
Perineural fibrosis of the plantar nerve where the lateral and plantar branches communicate
- located by between in the 3rd web space
- probably secondary to repeated trauma
Fibrosis results in a painful swelling of the nerve
- pain typically described as severe and burning
- aggravated by activity
F:M, 5:1
Morton’s neuroma - hx
Complains of “walking on a marble” or “winkle in sock”
Pain may radiate down to the 3rd and 4th toes
Tight shoes aggravate pain
Removing shoes and massaging foot relieves pain
Numbness in the affected toes may be present
Morton’s neuroma - PE
Exquisite tenderness with palpation between the 3rd and 4th metatarsal heads
Palpable nodule often present
Compression of foot may reproduce pain
Morton’s neuroma - tx
Appropriate shoe wear - Low-heeled, cushioned, wide toe box - Metatarsal pad Local injection of steroid with lidocaine may give temporary relief Sx resection is often necessary
Diabetic Foot - in general
Foot problems are the most common reason for hospitalization of a DM pt
More than half of all non-traumatic amputations are performed on DM
Diabetic Foot - Patho
Multi-factorial Integument - poorly fitting shoes Neurologic - DM peripheral neuropathy Vascular - microvascular damage Immunologic - inflammatory reactions
Diabetic Foot - hx
Glycemic control
Past hx of foot sx
Previous or current abx
Recent trauma to foot
Diabetic Foot - PE Inspection
Internal and external wear patterns - look at feet and shoes - callous formation Skin Hair growth Perfusion Pulses Color
Diabetic Foot - PE Examination
Bony prominences - increases potential for skin breakdown
Monofilament testing
Wounds measured for width, length and depth - describe extent of tissue involvement
Diabetic Foot - dx imaging
Needed to eval for Charcot foot
If concerned about osteomyelitis
- not seen on x-rays until advanced
- Technetium bone scan and MRI more sensitive to pick up early dz
Diabetic Foot - Tx
Find balance between foot function and preservation of tissue
Superficial lesion - Dressing changes, total contact casting
Deep lesion
- sx debridement
- hospitalization
- abx
- aggressive wound care
Diabetic Foot - Prevention
Proper footwear
Education if at risk for ulceration
Diabetic Foot - tx abscess
Emergent sx for drainage of infection, wound left open, dressing changes, definitive closure at later date or amputation
Diabetic Foot - tx gangrene toes / forefoot
appropriate amputation
Diabetic Foot - tx entire foot gangrene
appropriate amputation
Hallux rigidus - in general
arthritis of the MTP joint
Most common site of arthritis in the foot
Hallux rigidus - clinical presentation
Pain with activity esp. in toe-off position
Stiffness
Loss of extension at MTP is hallmark
Hallux rigidus - dx imaging
X-rays
Narrowing of MTP joint with osteophytes
Hallux rigidus - tx
Modified foot wear - large soft toe box - rocker bottom shoe NSAIDs Ice Sx - excision of osteophytes or arthrodesis
Hallux rigidus - Etiologies
F:M, 10:1 Tight pointed shoes Congenital deformity Severe flat foot Chronic Achilles tendon tightness Spascity Hypermobility of metatarsocuneiform joint RA
Hallux rigidus - hx
Pain
- medial eminence pain
- plantar 1st metatarsal or metatarsal head pain
Deformity
- impingement upon 2nd toe
- Resultant deformities of the lesser toes
Inability to wear certain shoes
Ask about - aggravating factors, occupation, level of athletic endeavors and type of shoe most often worn
Hallux rigidus - PE
Inspection
- Degree of deformity
- Callous formation
- Skin integrity
Palpation
- ROM of ankle, subtalar, transverse tarsal and MTP joints
- Neurovascular status
Hallux rigidus - dx imaging
X-rays - weight bearing
- AP
- Lateral
- Oblique
Note
- normal hallux valgus is <15°
- intermetatarsal angle
- Congruency of joint
- Arthrosis
- Size of medial eminence
Hallux rigidus - tx (non sx)
Shoes - adequate size and shape
Pads
Indication in cases of juvenile hallux valgus until pt is done growing
Indicated in high-performance athletes and dancers until unable to continue career
Hallux rigidus - tx (sx)
Not done for cosmetic reasons, but rather to correct symptomatic structural deformity Soft tissue - McBride only performed in mild Hallux valgus Osteotomy - Chevron - Akin - Metatarsal osteotomy - Keller Arthrodesis
Hammer toe deformity - in general
Plantar flexion deformity of the PIP joint
Flexible vs. fixed
Hammer toe deformity - clinical findings
Pain to dorsum of the toe
May have callous or ulceration
Deformity of nail
Hammer toe deformity - dx imagining
x-rays - helpful in the eval of
- proximal IP flexion deformity
- MTP hyperextension
- Hallux valgus
Hammer toe deformity - tx (non-sx)
Proper footwear - open toebox
Toe sleeves to correct deformity - only useful in flexible deformity
Hammer toe deformity - tx (sx)
Fixed deformity requires sx correction for proper shoe wear
Proximal phalangeal condylectomyand placement of K-wire
Correct any hallux valgus deformity to create room
Claw toes
Fixed extension of the MTP joint and flexion of the PIP & DIP
Usually affects all the lesser toes
Often related to neurological d/o or inflammatory arthritis
Mallet toe - in general
Flexion deformity of the DIP joint
May be fixed or flexible
Generally the second toe
Mallet toe - tx
Tx for both claw toes and mallet toes is similar to tx of hammer toe
Non-sx
- shoes with side toe box
- pads around toes
- OTC splints
Sx
- Correction of deformity
- may require release of flexor digitorum tendons
