Foot/Ankle

Question 1

Ottawa Rules (better to R/O fx)

Answer 1

Ankle: TTP at malleolus, unable to WB

Foot: TTP at base of 5th or navicular, unable to WB

Question 2

Orthotics

Answer 2

No evidence for LBP, can be helpful for PFPS with other modalities

Question 3

Orthotics for Plantar Fasciitis

Answer 3

Prefab better than custom, short term> long term

Question 4

Hallux valgus

Answer 4

Surgery > orthotics

Question 5

Pes Cavus

Answer 5

Custom orthotics OK

Question 6

Ankle sprain grading

Answer 6

Grade 1 - no loss of function, 10 degrees total motion loss (more laxity is classified as 3B vs. 3A)

Question 7

West point ankle scale

Answer 7

TTP Proximal > 4 cm to syndesmosis suggest high-ankle sprain (grade III),

Question 8

Ankle sprain recovery

Answer 8

Grade 1: 1-2 weeks
Grade 2: 2-3 weeks
Grade 3A: 4-5 weeks
Grade 3B: 7-8 weeks

*3B sprain takes almost twice as long to heal as grade 3!

Question 9

Risk factors for lateral ankle sprain

Answer 9

H/O ankle sprain
Improper warm-up
No external support
Impaired DF ROM
Don't participate in balance/NM training

Question 10

Ankle outcome measures

Answer 10

FAAM + LEFS (8-9 MCID @ 1 month)

No evidence for Hop tests

Question 11

Girth Assessment

Answer 11

Figure-8 (around base of 5th, achilles, dorsum and below malleoli)

Question 12

Special Tests

Answer 12

Anterior Drawer + TTP at ATFL + lateral hemorrhage is used to R/O rupture of ligament

Talar Tilt (not great) used for CFL ligament

Star excursion (

Question 13

Modalities

Answer 13

Strong evidence to use ice intermittently after injury to decrease pain and increase WB

Question 14

Acute ankle sprain treatment

Answer 14

MTT and progressive loading, sensory motor training

Question 15

Bracing

Answer 15

lace-up brace dec. sprains by 2-3x

Question 16

Ankle + nerve injury

Answer 16

Common concomitant N injury to fibular/tibial nerve with grade III ankle sprain

Question 17

To improve DF ROM

Answer 17

A-P talar mobilization
MWM
Ankle mortise HVLA

Question 18

CPR for HVLA to ankle after a sprain (3+/4)

Answer 18

Symptoms worse with standing
worse in evening
navicular drop > 5 mm
Distal Tib-Fib hypomobility

Question 19

Chronic ankle instability

Answer 19

Everter weakness

Question 20

Proprioceptive training

Answer 20

More effective if H/O sprains present

Question 21

Achilles tendinopathy

Answer 21

Vascularity is greatest in the muscle-tendon junction, worst at mid-tendon which is where pathology usually occurs (followed by the bone insertion).

Achilles is innervated by sural nerve

Stiffness and pain worse initially, gets better and then worsens (pain throughout activity once chronic).

Dec. strength with unilateral heel raise (normal = 1 rep/ 2 sec)

(+)Arc sign swelling moves with PF/DF

Royal London test (TTP dec. with ankle DF, worse with PF)

Thompson test (calf squeeze to assess for tendon rupture if no PF occurs)

Best Imaging U/S and MRI

Younger patients (age 33 mean) do better with conservative treatment than older patients (mean age 48)

Question 22

Treatment for achilles tendinopathy

Answer 22

Eccentric loading is most effective but can also use iontophoresis with dexamethasone or low level laser. Stretching and night splints are weak,

3x15 BID x 12 weeks is exercise Rx (better combined with air heel brace when not exercising)

Question 23

Foot pain DDx

Answer 23

AM pain = plantar fasciitis (Windlass test to R/I)
Big toe hyperextension = turf toe
Insidious swelling at 1st MTP = gout
numbness/tingling = tarsal tunnel vs. Morton’s neuroma (3rd/4th tarsals)
Mid heel pain which is worse barefoot and better with taping of the heel = fat pad atrophy

Question 24

Plantar Fasciitis

Answer 24

Heel Pain worse in AM and after prolonged walking, patients with impaired DF ROM and increased BMI are at highest risk
TTP at medial arch/Prox. attachment of the PF
Usually resolves in 13-14 months (normal clinical course)

Tx:Night splints, Pre Fab orthotics, Stretching of the PF 2-3x per day (3 minutes total), dexamethasone or acetic acid delivered with iontophoresis has moderate evidence.
Taping - short term relief (anti-pronation)
MTT - short term relief (1-4 months)

weak evidence for footwear, laser and weight loss Ed.

Question 25

Tarsal Tunnel Syndrome

Answer 25

Weak Toe Flexion
+ Tinel’s
Pain and numbness at arch (burning in the arch)
worse with running and/or prolonged activity

Effects the posterior Tibial Nerve and caused by overpronation or collapsed arch (tarsal coalition?)

Tx:arch supports, mobilization of the mid-foot, strengthening the foot intrinsics

Question 26

DDx for foot Nerve pathology

Answer 26

S1 radiculopathy will effect the gastroc/soleus
common peroneal neuropathy will present with a drop foot
Morton’s neuroma will effect the 3rd common digital nerve (best treated with neurolysis)

Question 27

Post. Tib tendonosis

Answer 27

(+)Too many toes sign
Pain with resisted inversion
Weak heel raise

Tx: supportive orthotics with eccentric strengthening

Question 28

1st MTP

Answer 28

Traumatic - turf toe
Microtrauma - sesamoid stress fx
Chronic - arthrosis, gout, hallux rigidus, hallux valgus

Assess ankle DF (usually impaired with 1st MTP pathology)

Question 29

Mulder’s sign

Answer 29

Squeeze the MTs and press with the thumb were nerve lesion is suspected (use for Morton’s neuroma)

Question 30

Freiberg’s disease

Answer 30

Collapse of the articular surface of 2nd metatarsal

Question 31

Gait symptoms

Answer 31

Heel Strike - cavus foot, congenital deformity, tight achilles
Midstance - ankle mobility deficit (DF)
Toe-off - Hammer-toe, metatarsalgia

Question 32

Primary metatarsalgia

Answer 32

painful at midstance, treated with MT bars that reduce pressure or injections

Question 33

Mallet toe

Answer 33

DIP flexion with PIP and MTP neutral (more common in women)