Foot/Ankle Flashcards
Insertional Achilles tendinopthy
- Within the 2cm proximal to insertion
- May also include bursitis, bony spurs, Haglund’s deformity
- Poorer prognosis than noninsertional
- Patients are frequently less active, overweight
- Avoid DF beyond neutral during eccentric training
- May be caused by impingement on Haglund’s deformity
Stages of posterior tibialis tendon dysfunction
I: Pain with palpation, painful ability to complete bilateral heel raises with no foot deformity
II: Weakness, tendon pathology, and flexible flat foot deformity
III: Fixed foot deformity
IV: Onset of arthritic changes > contact between calcaneus and lateral malleolus with severe hindfoot valgus. May have lateral ankle pain.
Sever’s disease
6-8 yo, taller, overweight
Associated with starting higher impact sports
Resolves in 2 weeks to 2 months
Bone grows faster than soft tissue > Greater stress at epiphysis.
Radiographs not helpful for diagnosis. One leg heel standing test is 100% Sn, squeeze test 97% Sn
Location of pain for medial tibial stress syndrome
Along posteromedial border of tibial. Must be diffuse, spread over at least 5cm
What percentage of plantar flexion strength comes from non-triceps surae plantar flexors (i.e. fibularis longus/brevis, FDL, FHL, posterior tibialis)
<20%
What muscle supports the transverse arch?
Fibularis longus. Attaches at base of first met/ medial cuneiform.
Also plantar flexes the ankle.
Muscles of the deep posterior compartment
FHL, FDL, tibialis posterior
Tibialis posterior is the strongest. FHL and FDL can’t substitute for tib. post.
Which muscles raise the medial longitudinal arch?
Deep posterior compartment muscles + foot intrinsics
What condition have toe flexors been found to be weak in?
Plantar fasciitis
Tibialis anterior insertion
Plantar surface of medial cuneiform and first metatarsal
Has 1/5 moment arm of tibialis posterior for supination
Can dorsiflex talonavicular joint (lowering the arch) if unopposed.
Function of intrinsic foot muscles
Arch support and propulsion.
Role in rehab is debated.
Average subtalar joint axis (oblique)
42 deg superior, 16 deg medial.
This is the axis about which supination/pronation occur.
Motion of each bone during supination
Calcaneus: Inversion
Talus: Abduction and dorsiflexion
Movement in talonavicular vs. calcaneocuboid joint
More in talonavicular.
Spring ligament
calcaneonavicular ligament.
Prevents excessive DF of navicular on talar head (supports medial longitudinal arch)
Midfoot locking theories
Pronation: Axes of calcaneocuboid and talonavicular joints are parallel
Supination: Axes are not parallel
Some data suggests midfoot rigidity is more dependnet on muscle support than axis alignment. Muscles are very active during gait. Overall the degree of muscular vs. passive support of medial longitudinal arch is not clear.
How does Achilles tendon force affect the medial longitudinal arch?
Lowers it
Tibial rotation in relation to arch height
External rotation raises arch.
Tibial rotation is likely controlled by proximal motor control patterns at hip/knee. Attempting to control tibial movement with foot orthoses may increase stress at the knee. Proximal muscle control may play an important role in flat foot posture.
Muscles primarily responsible for propulsion and support during gait
Plantar flexors.
Active from midstance until just prior to toe off
When do supination/pronation happen during gait?
Pronation from IC to foot flat (10-15% of stance)
Supination rapidly during terminal stance (after 50% of stance), peaking at 90% of stance.
Role of plantar flexors (triceps surae) in deforming medial longitudinal arch
Plantar flex the calcaneus. If this is unopposed this would > arch lowering during heel raise/ toe off.
There is conflicting data supporting passive vs. active support of the arch to counteract the plantar flexor deforming force.
Rehab considerations re: function of toe flexors
- Functional ROM is required >40 deg?
- High loads are transferred to the hallux in gait (20-50%?)
- Muscles function isometrically
Anatomy of flat foot posture
Plantar flexion of talus> overload to spring ligament.
Calcaneus and cuboid drift laterally > Hindfoot eversion posture.
Forefoot dorsiflexes and abducts
Results in midfoot instability. No rigid lever to transfer forces from Achilles tendon to the floor for push off.
Ligaments not affected by flat foot posture
Plantar fascia
Long/short plantar
Correlation between static and dynamic foot postures
Static posture may predict postures obtained during movement.
Pes cavus
Less common that pes planus, less well understood.
Common cause is neuromuscular problems in childhood and elderly.
High association with pain.
Conservative treatment typically focuses on using accommodating/ cushioning footwear.
Peek a boo sign
Clinician observes medial heel when looking at patient from the front. Indicates pes cavus.
Coleman Block test
Determines if the forefoot or hindfoot is influencing the arch.
Observe position of calcaneus in standing on flat surface and then standing with lateral calcaneus and mets on a one inch step
If calcaneal position changes from varus to normal with the block, deformity is flexibile. Orthotic should focus on forefoot. If no change, deformity is fixed. Orthotic should correct both forefoot and rearfoot.
Orthotics for pes cavus foot
Custom made are better than sham.
Goal: Shock absorption/ even distribution of pressure under the foot.
Are claw and hammer toes more common in pes planus or pes cavus?
Pes cavus
Which ankle condition is associated with decreased quality of life similar to end stage kidney disease, CHF, and cervical radiculopathy?
Ankle OA.
Outcome Measures for foot/ankle
PROMIS
VISA-A for Achilles tendinopathy
FAAM (Foot and Ankle Ability Measure)
LEFS
Have studies shown that rehab can affect foot posture?
No.
Studies do show a relationship between foot posture and injury patterns.
Arch Heigh Index
Dorsum height/ truncated foot length
1SD above mean = supinated posture. 1SD below mean = pronated posture.
Normal for arch heigh to decrease about 1 cm when going from NWB to 50% WB in standing.
Navicular drop test
In standing, patient’s foot is placed in subtalar neutral position. Measure height from floor to navicular. Then have patient relax their foot posture and measure again.
>10 mm difference is abnormal/ positive
Conflicting evidence re: association between navicular drop test and injury.
Heel raise standards
25 reps (+/- 13) Heel should get 10-12 cm from floor
Patients lacking subtalar inversion during heel raise assumed to have significant posterior tibialis weakness.
Reliability of ankle ROM measurement
Good for DF
Not so good for PF
Normal ankle DF PROM in supine
18 deg
Definition of hallux limitis
Passive hallux DF <40 deg
Position of talocrural joint during talar tilt test to bias different ligaments
PF: ATFL
DF: CFL
(test might not be sensitive enough to distinguish between ATFL and CFL injuries)
Position of talocrural joint for anterior drawer test
10-20 deg plantarflexion
Metrics of DF-ER test for high ankle sprain
Good sensitivity (71%) Moderate specificity (63%)
Metrics of squeeze test for high ankle sprain
Poor sensitivity (26%) High specificity (88%)
(Squeeze just above midpoint of calf)
Metrics of syndesmosis ligament palpation for high ankle sprain
High sensitivity (92%) Poor specificity (29%)
Metrics of Thompson test
High sensitivity (96%) High specificity (93%)
Metrics of Achilles palpation for tendinopathy
Moderate sensitivity (64%) High specificity (81%)
Royal London Hospital test
\+: Decreased pain with palpation of Achilles when ankle is actively dorsiflexed. Moderate sensitiivty (54%) High specificity (86%) Good reliability
Arc sign
\+: Swollen region of Achilles moves along with tendon during active ankle DF/PF Moderate sensitivity (42%) High specificity (88%)
Metrics for Windlass test
Low sensitivity (33%) High specificity (99%)
Normal alignment of midtarsal joint on lateral XRay
S shaped.
Angles used to measure foot posture on XRay
Calcaneal pitch angle
1st met pitch angle
Bohler’s angle (<20 deg indicates calcaneal fx)
Fowler-Phillip and Chauveaux-Liet (indicate calcaneal impingement on Achilles)
Ultrasound to identify tendinopathy vs. inflammation
Dark (hypoechoic) regions within tendon indicate abnormal tendon structure
Fluid (dark) around the tendon indicates peritendinitis/ bursitis
Collagen appears bright (hyperechoic)
Normal foot posture throughout lifespan
Infants born with flat foot, develop normal footprint around age 12-13.
Wearing shoes during development of the foot may be associated with development of flexible flat foot deformity
Adult acquired flat foot deformity
Defined as unilateral deformity.
Most common cause is TPTD
Hallux valgus
Subluxation of first MTP, deviation >15 deg
Present in 23% of adults, 36% > 65 yo
>60% of patients have a family history
2-3x more common in females
Likely contributes to increased fall risk
Deformity will progress unless fixed surgically.
Mixed results following surgery. Evidence supports PT after surgery.
Hammer Toe
PIP flexion deformity with 1-2 toes involved
Claw toe
IP flexion + MTP extension
Often present in all toes and caused by neuromuscular disorder.
Metatarsalgia common
Treatment of Hammer/Claw Toe
If flexible, can tape MTP joint into flexion. This improves mechanics of EDL to extend PIP joint
Shoe wear: larger toe box, padding on pressure areas
Rigid deformity: Surgery required.
Mallet toe
Flexion of DIP.
Can occur in isolation or secondary to hammer toe.
Most often at second toe. Possibly due to tight fitting shoes.
Corn often develops plantar to the nail bed.
High ankle sprains
Common in contact sports and sports where foot is immobilized (e.g. skiing).
Can > chronic instability and arthritis if diagnosis is missed. Refer if suspected.
MRI is best for determining if instability is present.
Treatment of tibiofibular instability
Cast immobilization or internal fixation
High ankle sprain management
Grade I: Initially limit DF ROM, strong PF contraction, and weight bearing.
Grade II: Need cast/ surgery.
Lateral ankle sprains
Females: Males 2:1
Most common mechanism is contact with another person.
One sprain doubles risk for subsequent sprain.
Diagnosing laxity improves after initial swelling and hematoma subside
ATFL healing is poor, instability likely.
20-40% of patients experience chronic ankle problems associated with lateral ankle sprain.
Identifying fracture with inversion sprain
First priority. 10-15% of lateral ankle sprains involve foot or ankle fracture.
Ottawa ankle rules
Failure to improve after a few weeks indicates need for follow up radiographs
Ottawa ankle rules
Radiographs needed if any of the following are present:
- Pain in malleolar zone or along talar neck/ head
- Bone tenderness posterior edge or tip of malleoli, base of 5th met, or navicular
- Inability to weight bear immediately following injury and during exam
Pain in midfoot zone (5th met/ navicular) indicates foot series
Pain in malleolar zone indicates ankle series
Signs at 4 weeks post-injury that predict continued functional problems at 16 weeks:
Weight bearing dorsiflexion pain
Medial joint pain.
Supervised vs. unsupervised rehab for lateral ankle sprain
Supervised > less pain and instability at 8 weeks, greater gains in ankle strength and joint position sense, worse postural control at 4 month follow up.
No differences in pain and instability at longer term follow up
Inconclusive results re: prevention of reinjury at 12 months
Patients most likely to respond well to manual therapy after lateral ankle sprain
- Pain worse with standing
- Pain worse in evening
- Navicular drop > 5 mm
- Distal tibiofibular hypomobility
Chronic Ankle Instability
Defined as:
- At least one lateral ankle sprain
- At least 2 episodes of ankle giving way in the last 6 months
- Lower self-reported function
Associated with increased fear of reinjury
May or may not be associated with positive joint laxity tests
Cumberland Ankle Instability Tool, balance, and functional tests used for diagnosis.
Anatomical risk factors for CAI
Increased talar curvature
Anterior positioning of the talus
Mechanical instability after a sprain contributes little to the development of CAI. More patients experience perceived instability.
Treatment of CAI
- Exercise training, often hop stabilization training.
One study had patients train the uninjured ankle and led to improvement in injured ankle. > CAI likely driven by central mechanisms requiring sensorimotor reorganization. - Improving ankle DF mobility and other joint restrictions (manual therapy)
Mechanical ankle instability
Defined as positive talar tilt > 7 deg, anterior displacement > 4mm.
Key indicator for surgery is failed conservative treatment with persistent pain and recurring injuries. Patients likely to have had CAI for years.
Associated conditions (loose bodies, chondral defects, anterior scar tissue) often present.
Commonly have decreased ankle strength and ROM
Rehab is the same as for CAI, most patients don’t need surgery.
Anterior impingement syndrome
Primarily occurs as a result of ankle trauma, typically lateral ankle sprain. Repetitive microtrauma at anterolateral talocrural joint line > scar tissue formation
Often treated conservatively, but surgery is an option. Bony osteophytes will likely regrow.
Loose bodies and osteochondral defects
- Common in patients with CAI
- Medial talar dome is most frequently involved
- Re-evaluation for these defects is recommended at 4-6 weeks if patient isn’t progressing
MRI for identifying osteochondral defects
Low sensitivity (42%) except for severe cases High specficity (96%)
Consensus statement recommends arthroscopy prior to ligament reconstruction.
Ankle OA
- Not common, affects 1-4% of population
- Less common due to thick articular cartilage
- Majority of cases are post-traumatic (fx or repeated sprains)
- Onset is usually at a younger age due to association with trauma
- Typically talocrural but can also involve subtalar and talonavicular joints
- Treatment: Ankle replacement or ankle arthrodesis
Plantar fasciopathy risk factors
Age 45-60
Overweight
Bilateral limitations in ankle DF
Occupation or leisure activity that requires prolonged standing.
Key diagnostic indicators for plantar fasciopathy
Medial plantar heel pain most severe with initial weight bearing and extended weight bearing Pain with palpation of PF insertion Limited DF A/PROM Windlass + FPI abnormal BMI high
Signs of calcaneal stress fracture
Diffuse swelling and warmth in hindfoot
Squeeze test +
Typical clinical course of plantar fasciopathy
10+ months
80% see significant improvement in sxs
Overal positive prognosis, but complete relief of sxs can be elusive.
Taping in plantar fasciopathy
Effective short term for pain relief
Orthotics for plantar fasciopathy
Strong support for short- to long-term benefits. No added benefit of custom vs off the shelf.
Stretching gastroc/soleus for plantar fasciopathy
Strong support for short-term pain relief
Night splints for plantar fasciopathy
Strong support for 1-3 months of wear.
Type of night splint doesn’t matter
Manual therapy for plantar fasciopathy
Useful when combined with other treatments.
Modalities for plantar fasciopathy
Not recommended (not an inflammatory process)
Why might limited hip ER ROM influence plantar fasciopathy sxs?
> Decreased ER throughout LE > lower of medial longitudinal arch.
Tarsal coalition
- Rare
- Only 25% of people are symptomatic
- Fusion of bones in the midfoot and hindfoot
- Sxs most common in adolescents age 12-16 (when coalition ossifies and begins to restrict ROM)
- Can also occur in adults after trauma, surgery, or arthritis
- Pain may result from microfx at coalition-bone interface
- 40-80% have bilateral involvement
- Inherited
Most common joints for tarsal coalition to occur
Calcaneonavicular
Talocalcaneal
Diagnosis of tarsal coalition
- May initially present as an ankle sprain (lack of subtalar movement can leave pts at increased risk for sprain)
- Family hx
- Repeated ankle sprains
- Vague hindfoot pain, worse with activity
- Tenderness over sinus tarsi or sustentaculum tali
- Hindfoot valgus
- Limited subtalar movement
- Shortening of fibularis previs and longus
Imaging conferms dx. Radiographs initially, MRI or CT may be needed. MRI better for fibrous coalitions and concomitant tendon pathology.
Treatment of tarsal coalition
- Activity modification
- Orthotics (medial heel wedge, arch supports)
- Antiinflammatory drugs
- ^If ineffective, cast immboilization for 4-6 weeks to reduce stress on joints, allow microfx to heal.
- Surgery recommended if fail conservative mgmt
Post op outcomes for tarsal coalition
- <14-16 yo do better
- Worse outcomes if coalition is bony (vs. cartilaginous), large coalitions, larger calcaneal vaglus, presence of degenerative changes.
Lisfranc ligament
From medial aspect of first cuneiform to base of second metatarsal.
Lisfranc injuries mechanism
- High energy injury occurring during sports, or low energy injury during MVA
- Occur from longitudinal forces applied to a plantar flexed ankle and foot
Clinical presentation of Lisfranc injury
- Deformity of complete rupture has occurred
- Swelling, pain on medial side of foot
- Screen for imaging with midfoot squeeze test and ability to single leg hop.
Diagnosis of lisfranc instability with imaging
> 2 mm spacing between 1st and 2nd metatarsal bases on AP radiographs suggests instability
High false negative rate with radiographs
Treatment for Lisfranc injuries
- Stage I: NWB cast for 6 weeks
- Stage II and III: ORIF, NWB for 8 weeks. Progress to FWB by 12 weeks. Screw removal at 12-24 weeks depending on weight of patient. Custom medial arch support once weight bearing.
Sever’s disease treatment
Rest Ice Heel lift/ shoe inserts Strengthening Stretching Analgesics not warranted unless sxs don't improve. Wear supportive footwear
Kohler’s disease
Osteochondrosis of navicular (similar to Leg Calve Perthes)
Age 2-10
Boys
Unilateral
Self limiting within 8 months
Etiology unknown, possibly infection, inflammation, endocrine imbalance, nutritional factors, disturbance in dorsalis pedis and/or medial plantar arteries.
S/s of Kohler’s disease
- Normal lab values, no infection, no trauma
- Gradual onset of pain
- Swelling, erythema over dorsum of midfoot
- Tenderness to palpation of navicular
- Shifting weight to lateral side of foot for pain relief.
- Radiographs can help but must correlate with clinical findings
Treatment of Kohler’s disease
- Soft arch support
- Avoidance of strenuous activity
- Short leg cast prescribed for severe cases
- Type of treatment is not associated with a difference in long term outcomes
- Surgery is rare. Would include arthrodesis of calcaneocuboid and talonavicular joints
Hallux rigidus
- Caused by degenerative arthritis
- Pain accompanies loss of motion
- Females
- Lateral forefoot pain is common due to load transfer
- Causes: Traumatic injury, repeated hyperextension motions, family hx
- Disease progresses through adolescence to adulthood
Staging of hallux rigidus
0: 40-60 deg DF, no pain
1: 30-40 deg DF, dorsal osteophytes
2: 10-30 deg DF, lateral/medial osteophytes and joint narrowing
3: <10 deg DF, severe radiographic changes, constant moderate to severe pain and pain at extremes of ROM
4: Same as 3, but pain throughout entire ROM
Conservative hallux rigidus treatment
- Limiting first MTP joint motion (taping, stiff soled deep toe box shoes, orthotics)
- Distraction and extension joint mobilizations
Surgeries for hallux rigidus
- Cheilectomy - removal of bone spurs
- Proximal phalanx osteotomy - removing a wedge of bone from proximal phalanx
Standards of practice vary across the country
Metatarsalgia and Sesamoiditis
- Most common along first and third MTP joints
- Absence of interdigital space pain helps exclude neuroma
- Cause: Overloading of forefoot
- Dx by location of pain, presence of calluses
Treatment of metatarsalgia and sesamoiditis
Reduce load on forefoot
- Metatarsal pads
- Stretching Achilles. Gastroc lengthening common
- Sesamoidectomy. Remove only one or part of each preserves joint mechanics. 50% of pts still have pain after surgery.
Morton neuroma
- Perineural fibrosis
- Nerve degeneration of common digital nerve
- Bw 3rd and 4th mets
- Rarely bilateral
- Pain (sharp, burn), dysesthesias, numbness in forefoot
- Aggravated by narrow toe box and high heels
- Develops due to overuse with excessive toe dorsiflexion
Dx of morton neuroma
- MRI and ultrasound have similar metrics
- Reproduction of sxs with plantar pressure between the met heads
- Painful click with squeezing the forefoot and palpation of neuroma (Mulder sign)
- Relief of pain following injection
Treatment of Morton neuroma
- Steroid injection common, lacks evidence for use
- Unloading area around the nerve (biomechanics). Evidence for conservative treatments is limited.
- Soft soled shoes with wide toe box
- Surgical excision common, outcomes vary
Risk factors for Achilles tendinopathy
41-60 yo Obesity Limited DF ROM Abnormal subtalar ROM Decreased PF strength Abnormal tendon structure Comorbidities Training errors
Non insertional tendinopathy
- 6cm proximal to insertion
- Most common
- Pain with activity
- Stiffness upon weight bearing after immobility, beginning of exercise
- Need to identify whether inflammatory process is happening. If there is swelling, it will not move with the tendon during AROM.
Use of orthotics/ heel lifts for Achilles tendinopathy
Insufficient evidence.
Individuals more likely to respond well to eccentric loading for Achilles tendinopathy
Athletic individuals
12 week program recommended (3x15 with knee extended and flexed).
Manual therapy, taping, night splints for Achilles tendinopathy
Manual therapy, taping: Low levels of suport for use
Night splints not recommended
Prognosis for noninsertional Achilles tendinopathy
Overall good, most improve within first 3-6 mo of treatment
Many patients will not be able to return to prior level of physical performance without symptoms.
Achiles tendon rupture
- Increasing incidence over the past decade
- Men, 40-60 yo
- Conservative and surgical management have similar rates of rerupture and incidence of DVT
- Functional rehab (early FWB and ankle mobilization) > better outcomes. Initially immobilized in PF, don’t go beyond neutral into DF until 7 weeks.
Posterior tibial tendinopathy/ dysfunction
- Leading cause of acquired flat foot deformity. Most evidence suggests this precedes ligament failure.
- Females, overweight
- Progressive, early treatment important
- Tendinopathy in tendon distal to malleolus, but muscle belly can also atrophy
Treatment of posterior tibial tendon dysfunction
- Brace that anchors support proximally to the tibia to unload tendon, limits hindfoot eversion/inversion, and supports medial longitudinal arch. 15 months
- Hinged ankle AFO preferred. Solid ankle may be necessary in Stage III/IV. Better than orthotic in more severe cases. May not matter in less severe cases.
- Exercises that induce remodeling of the tendon, prevent weakness of the leg muscles, and cause hypertrophy of atrophied muscles
- At 8 year follow up, only 20% of patients could do a normal single leg heel raise.
- Ongoing condition with intermittent episodes.
- Goal of treatment: Minimize disability, mitigate progression of flat foot deformity
Fibularis dysfunction
- Most commonly associated with lateral ankle sprain (acute trauma)
- Can also occur due to subtle pes cavus (repetitive damage)
- Tears frequently occur longitudinally, resulting from subluxation or riding around the lateral malleolus.
- Cyriax exam
Special test to detect subluxation of fibularis tendons
Resisted ankle dorsiflexion and subtalar eversion
Treatment of fibularis dysfunction
- Anatomical cause: Surgery
- Orthotic for cavus foot
- Strengthening everters
General treatment for foot/ankle fx
Immobilization lasting 6-8 weeks
Outcomes after fx
Worse if:
Older men
More complicated fxs (bimalleolar or trimalleolar)
Overall can expect rapid recovery in first 6 months followed by varied and slow recovery after that.
Weber classifications for ankle fractures
A: lateral malleolus distal to tibial plafond. Often nonsurgical. WB after immobilization
B: At level of tibial plafond. ORIF> early WB
C: Proximal to tibial plafond. ORIF> early WB
B, C may involve sydesmosis and malleolar tertius (trimalleolar fx)
Higher rates of arthritis in Weber type C
Ankle DF ROM post ankle fx
Remains limited at 3 months post injury.
Weak correlation with outcomes
Ankle fx treatment
Choice of WB and early mobilization (post stabilization) will vary by physician.
No good evidence to guide rehab.
Most studies report ongoing pain, swelling, and functional deficits. However, most pts return to previous level of function.
Metatarsal fractures
- Immobilized if not displaced. Otherwise ORIF.
- Avulsion of 5th met: 6-8 weeks immoblized
- Jones fx (stress fx): propensity to not heal
Calcaneal fractures
- Diagnosed with Xray and CT due to complexity (commonly comminuted and oblique)
- Often due to fall from height> significant axial load
- Anatomical realignment can be difficult
- High complication rates of ORIF
- Rehab is similar to post ankle fx, but also need to emphasize subtalar joint mobility
- NWB 6-8 weeks but ROM can start within 1 week
- Pts frequently have to change sports
What part of bone do stress fractures typically happen in?
Cortical (compact) bone
When should running shoes be replaced?
300-500 miles
Risk factors for stress fx
- Osteoporsis
- Female athlete triad
- Smaller calf girth
- Less muscle mass of lower limb
- Running with excessive hip adduction and rearfoot eversion (tibial stress fx)
- Increasing training too quickly
S/s of stress fx
- Pain at a specific distance into the run
- Can start to have pain at shorter distances and/or at rest
- Focal point tenderness is the key sign
Site of stress fx and common sport associated
Navicular: Sprinters, hurdlers, middle distance runners
Tibial: Distance runners, military recruits
Treatment of stress fx
- Rest
- Tibial: Pneumatic walking boot. Return to athletics at 8 months
- Navicular: Nonweight bearing cast. RTS 8 months
- Metatarsals: 6-8 weeks NWB
Medial tibial stress syndrome
- Often bilateral, distal two thirds of posterior tibia
- Female, higher BMI, below average activity history, previous lower extremity injury, greater navicular drop
- Not necessarily a continuum to stress fx
- **NOT associated with limited DF ROM
Diagnosis of MTSS
- Pain >5cm along posteromedial border of tibia
- Pain aggravated by palpation and exercise
- Only occurs at rest when severe (as opposed to compartment syndrome)
- Diagnostic injection can be used
Treatment of MTSS
- Relative rest up to 4 months
- Ice, NSAID injection
- Identifying and modifying the source of repetitive stress
- Surgical approaches include fasciotomy, cauterization of affected periosteum
- Possibly ECSWT but more research needed.
