Foot/Ankle Disorders

Question 1

Achilles Tendon Tear

Answer 1

• Mechanism:
  
  • mechanical overload from eccentric contraction of gastrocsoleus complex
• Area:
  
  • Tendon midsubstance: 72%
  • -Near Myotendinous junction: 9%
  • -Calcaneal insertion: 19%
• Risks:
  
  • Sports-related injury (non-contact), “weekend warrior”, fluoroquinolone use, 30-50yo males
• Epidemiology:
  
  • 2nd most common tendon rupture (after biceps)
• S/sxs:
  
  • *Sudden onset
  • -Severe, calf & heel pain after push-off movement
  • • “Pop” or “gunshot wound”
  • -inability to bear weight
  • -distal leg swelling, bruising, or stiffness
• Watershed zone: 2-6cm proximal to the insertion where it is considered hypovascular.
• PE:
  
  • Thompson test: weak, absent plantar flexion (flat foot) when the gastrocnemius is squeezed
  • -Palpable dell (defect in the tendon)
• Dx:
  
  • *Imaging not helpful or required
  • -Radiography: to r/o fracture, disruption of Kager’s triangle
  • -US: measure gapping
  • -MRI: best test, only if unclear
• Tx:
  
  • Nonoperative: splint initially in mild plantar flexion with subsequent splinting employing gradual dorsiflexion toward neutral
  • -Surgical: allows for early ROM

Question 2

Ankle Sprain

Answer 2

• Definition:
  
  • stretching or tearing of ankle ligaments.
  • most common cause of lower extremity injury
• Ligaments:
  
  • Lateral ligament complex: Anterior talofibular (ATFL: always tears first → most common), calcaneofibular(CFL), & posterior talofibular ligaments, plantar flexion & inversion injury, common (~75%)
  • -Medial: deltoid ligaments, eversion, rare
• S/sxs:
  
  • *Acute onset
  • -”Pop” followed by ankle pain & swelling
  • -Ecchymosis
  • +/- ability to bear weight
• PE:
  
  • Localized ATFL tenderness
  • -Anterior drawer test: assesses ATFL integrity,>3mm of displacement compared to uninjured side
  • -Talar tilt test: assesses CFL stability, >5 degrees compared to uninjured side
  • -Palpate lateral & medial malleoli of the tibia & the base of the 5th metatarsal for tenderness & crepitus → suggests fracture!
• Dx:
  
  • Radiography: anterior drawer & talar tilt, used to r/o fracture
  • MRI can eval ligament & surrounding fluid
• Classifications:
  
  • -Grade I: ATFL stretched
  • -Grade II: ATFL tear +/- CFL tear
  • -Grade III: ATFL, CFL, & capsular tear
• Tx:
  
  • Non-operative: RICE, NSAIDs, crutches x 3days, taping/bracing (ASO), orthotics (lateral heel skive, forefoot valgus wedge)
  • -Operative: for persistent symptomatic instability & failed rehab (>3 months)

Question 3

Ottawa Ankle Rules for Sprains vs Fractures

Answer 3

Question 4

The Diabetic Foot: Overview

Answer 4

• Types of Neuropathy:
  
  • Sensory: numbness or tingling, prickly sharp pain or burning
  • -Motor: muscle weakness, loss of balances, changes in foot shape (increases pressure)
  • -Autonomic: dry, cracked skin
• S/sxs:
  
  • *May have no sxs
  • -burning, tingling foot pain at night
  • -Ulcers
• PE:
  
  • Monofilament test: applies pressure to plantar aspect of foot to determine sensation
• Tx:
  
  • *Goal: Pt education & prevention
  • -Protective foot care (never walk barefoot)
  • -Inspect feet daily for wounds

Question 5

Diabetic Ulcers of the Foot

Answer 5

• Pathophys:
  
  • -Neuropathy: absence of protective sensation
  • -Deformity: structural abnormalities
  • -Trauma: short duration or repetitive (not perceived d/t impaired neurofeedback)
• S/sxs:
  
  • insensate ulcer
• PE:
  
  • Blunt bone probe: see if cotton swab can reach the bone that the ulcer overlays → likely osteomyelitis if it can
  • Need to determine if it is infected, PAD, adequately offloaded
• Dx:
  
  • XR, Labs: ESR, CRP, Cx & gram stain
• Tx:
  
  • Remove pressure causing the ulcer & allow it to heal
  • Accommodative footwear, orthotic device
  • Surgery for deep ulcerations
    *

Question 6

Charcot Arthropathy

Answer 6

• Mechanism:
  
  • repetitive stress in a pt in whom pain & proprioception sensation is abnormal → progressively disrupts joint stability & bony deformities
• Areas:
  
  • Lisfranc joint = most common, rocker bottom deformity, increased fraction at MT bases at dorsum of foot
  • -Chopart joint: abnormal plantar pressure & medial-lateral widening
  • -Others: subtalar joint, tibiotalar joint, forefoot
• S/sxs:
  
  • Acute:
    
    • Joint swelling, warmth, & redness, NONtender
  • Chronic:
    
    • -joint or foot deformity
    • -alteration of foot shape
• PE:
  
  • hot, red swollen joint with intact skin
  • -Bounding pulses
  • -Elevate foot above the heart for 1 minute → loss of redness
• Dx:
  
  • XR: may be negative if acute, Charcot degeneration (obliteration of joint space, joint disorganization)
  • -MRI or bone scintigraphy: may be needed to r/o osteomyelitis
  • DDx: cellulitis, osteomyelitis, gout
    
    • ***often mistaken for osteomyelitis
• Tx:
  
  • Conservative: total contact cast, no weight bearing
  • Severe: surgical resection of a bony prominence or reconstruction if severe deformity

Question 7

Fractures/Dislocation of the Midfoot (Lisfranc)

Answer 7

• Definition:
  
  • traumatic disruptions of the tarsometatarsal joints. One or more metatarsal bones are displaced from the tarsus
• Pathophys:
  
  • the second metatarsal wedges into a slot in the cuneiforms & is key to stabilizing the other tarsometatarsal joints. Lisfranc ligament is responsible for stabilization of the arch. Disruption b/w the articulation of the medial cuneiform & base of the 2nd metatarsal → ligamentous injury or fracture
• Risks:
  
  • slamming on car breaks, trip in a hole
• S/sxs:
  
  • Pain & swelling in the midfoot
  • -Ecchymosis in the plantar arch (pathognomonic)
  • -Hypermobility
  • Pain with abduction or pronation
• PE:
  
  • Tenderness & swelling over the tarsometatarsal joint
  • -Ecchymosis of the plantar arch = pathognomonic
  • -Stabilize the hindfoot with one hand and rotate/abduct forefoot with the other hand → severe pain
• Dx:
  
  • **Dx is easily missed (diagnosed as a sprain)
  • -Weight bearing radiographs (AP, lateral, oblique): lateral deviation of the 2nd metatarsal base with a small avulsion fracture between the base of the 1st & 2nd metatarsals, diastasis > 2mm, Fleck sign (fracture at the base of the 2nd metatarsal where the lisfranc ligament avulsed some bone)
• Tx:
  
  • -Displacement: Surgical ORIF
  • -Nondisplaced: 6-8 weeks non-weight bearing cast
  • Hardcastle Classification:
  • -Type A: total displacement
  • -Type B: partial displacement
  • -Type C: divergent

Question 8

Fractures of the Ankle

Answer 8

• Definition:
  
  • injuries to the lateral malleolus (distal fibula), medial malleolus, posterior malleolus (posterior lip of the tibia), collateral ligamentous structures, &/or the talar dome.
• Types:
  
  • -Transverse: produced by a ligament pull of injury
  • -Oblique: straight or spiral oblique produced by talar compression or push-off injuries
• S/sxs:
  
  • *Acute onset ankle pain & swelling following trauma
• PE:
  
  • Marked tenderness at fracture site
  • -Palpate the proximal fibula to assess for a Maisonneuve fracture
  • -Neurovascular exam
• Dx:
  
  • XR: *AP, lateral, mortise views
  • -Most fractures are visible, but if minimally displaced may not be able to see it
  • Danis-Weber Classification:
  • -Type A: below the syndesmosis
  • -Type B: at the syndesmosis
  • -Type C: above the syndesmosis
• Tx:
  
  • Stable: weight-bearing cast x 4-6 weeks
  • -Unstable, non-displaced: non weight bearing cast
  • -Unstable, displaced: closed or open reduction

Question 9

Fractures of the Calcaneus & Talus

Answer 9

• Definition:
  
  • fractures of the two bones of the hindfoot, usually from severe trauma. Rarely occur together.
• mechanism:
  
  • sheer vertical force of the talar process → body of calcaneus→ Achilles avulsion (direct axial load/high energy)
• Risks:
  
  • males, MVA or fall from a height
• Presentation:
  
  • hanging Christmas lights, swinging on a rope into shallow river (bilateral)
• S/sxs:
  
  • *Acute onset
  • -Heel pain & Swelling
  • -Heel ecchymosis
• PE:
  
  • Mondor’s sign: plantar medial ecchymosis
  • **Calcaneus is extremely vascular so if you crack it → LOTS of blood
  • -Skin tenting
  • -inability to bear weight
  • -Fracture blistering around heel
  • Check nerves & cap refill
  • -Palpate spine (may be associated with spine compression fx)
• Dx:
  
  • Need to determine if intra-articular ( 75%) or extra-articular (25%)
  • XR: *AP, lateral, Harris heel views
  • -Assess Bohler’s Angle to determine joint depression (decrease in angle)
• Tx:
  
  • Immediate: splinting with a well-padded posterior splint, elevated extremity. RICE
  • -Surgery: reduction & fixation

Question 10

Metatarsal Fractures

Answer 10

• Definition:
  
  • fracture of the forefoot
• Risks:
  
  • sudden increase in activity
• Epidemiology:
  
  • 5th metatarsal = most common in adults, 1st metatarsal = most common in children, 3rd metatarsal = most common stress fracture
• S/sxs:
  
  • Forefoot pain & swelling on weight bearing
• PE:
  
  • -Swelling, ecchymosis, & pinpoint tenderness
  • -Chandelier sign when palpating over metatarsals
• Dx:
  
  • XR: *AP, lateral, oblique
  • -Demonstrate fracture (stress fracture may not show up for 2-3 weeks)
• Tx:
  
  • *Goals: maintain transverse & longitudinal arch of forefoot, restore alignment to allow normal force transmission across metatarsal heads
  • -Short leg cast, fracture brace, or wooden-soled shoe
  • -WEight bearing as tolerated
  • -Zone 1: air stirrup, wooden-soled shoe, fracture brace
  • -Zone 2: cast immobilization, non-weight bearing
  • -Zone 3: surgical intervention

Question 11

Jone’s Fracture

Answer 11

• Definition:
  
  • transverse fracture through the diaphysis of the 5th metatarsal at the metaphyseal diaphyseal junction
• S/sxs:
  
  • Pain over the 5th metatarsal area & lateral border of the midfoot especially with weight bearing
• Dx:
  
  • XR: transverse fracture involving the metaphyseal-diaphyseal junction
• Tx:
  
  • -Non-weight breaking in a short leg cast x 6-8 weeks
  • -May require ORIF/pinning

Question 12

Dancer’s Fracture (PseudoJones)

Answer 12

• Definition:
  
  • fracture through the base (tuberosity) of the fifth metacarpal d/t plantar flexion with inversion
• Tx:
  
  • Walking cast x 2-3 weeks
  • -ORIF if displaced

Question 13

Sesamoid Fracture

Answer 13

• Definition:
  
  • The 1st MTP joint has two sesamoids (medial & lateral). Medial sesamoid bears great force during gait → more commonly fractured
• Mechanism:
  
  • avulsion forces (hyperdorsiflexion of the 1st MTP joint), repetitive stress, trauma
• S/sxs:
  
  • Pain under the first metatarsal head +/- swelling, ecchymosis
• PE:
  
  • -Localized pain over the fractured sesamoid
  • -Pain moves with the sesamoid as the great toe is flexed/extended
  • -Restricted ROM of the 1st MTP joint
• Dx:
  
  • XR: * AP, lateral, axial view
  • -May need MRI or bone scan
• Tx:
  
  • Removable short leg fracture brace or a stiff-soled shoe with a rocker bottom
  • *healing can take 6-12 months

Question 14

Pilon Fracture

Answer 14

• Definition:
  
  • fracture of the distal tibia from the impact with the talus (axial load) → interrupts the ankle joint space
• S/sxs:
  
  • Severe pain, swelling, & deformity
• Tx:
  
  • Surgery → ORIF
    *

Question 15

Morton’s Neuroma

Answer 15

• Definition:
  
  • Perineural fibrosis of the common digital nerve as it passes between the metatarsal heads.
  • Most commonly occurs between the 3rd & 4th toes (3rd webspace)
• Risks:
  
  • 25-50 yo females (probably d/t tight shoes)
• S/sxs:
  
  • burning pain in the ball of the foot aggravated by tight shoes
  • -”wrinkle in my sock” or “walking on a marble”
  • -Numbness & paresthesias in the toes adjacent to the involved web space
• PE:
  
  • Palpable mass or “click” between toes
  • -Squeeze test: apply direct plantar pressure to the interspace with one hand & then squeeze the metatarsals together with other hand → increased pain & tenderness radiating to the toes, click/grinding (Mulder sign)
  • -Have patient stand on piece of paper & trace their foot → distorted reality of the width of their foot
• Dx:
  
  • Clinical dx
    XR: to r/o stress fractures or arthritis, will be normal
• Tx:
  
  • Shoes with wide toe box & low heel, forefoot rocker
  • -Orthoses (metatarsal pads, metatarsal cookies)
  • -Injections: corticosteroids
  • -Surgery: rare, excision of the neuroma

Question 16

Metatarsalgia

Answer 16

• Definition:
  
  • a general term for forefoot pain localized under one or more of the lesser metatarsals
• Mechanism:
  
  • gastrocnemius effect (tightening of the muscle → pressure on plantar flexion)
• Presentation:
  
  • 60-80yo with thinning & displacement of the plantar fat pad into the sulcus with a contaminant digital deformity (claw or hammer toe)
• S/sxs:
  
  • Diffuse pain in the ball of the foot
  • -Diffuse callus formation
  • “Walking on pebbles”
• PE:
  
  • Observe alignment of toes
  • -Palpate for swelling/masses along the plantar & dorsal aspects of the metatarsals
  • -Note extent of calluses
• Dx:
  
  • XR: weight bearing AP & lateral of the foot to assess metatarsal & toe alignment
• Tx:
  
  • Accommodative shoes, metatarsal pad, orthotics
  • -Calf & hamstring stretching 6-7x/day for 30 seconds
  • -NSAIDs, ice

Question 17

Plantar Fasciitis

Answer 17

• Definition:
  
  • inflammation & microscopic tears of the plantar fascia due to overuse (especially with flat feet, high arches, heel spurs). Plantar fascia arises from the medial tuberosity of the calcaneus & extends to the proximal phalanges of the toes
• Mechanism:
  
  • degenerative tear of part of the fascial origin from the calcaneus followed by a tendinosis-type reaction
• Risks:
  
  • women, overweight, runners
• S/sxs:
  
  • **Insidious onset
  • -inferior heel pain worse in the morning & after a period of rest, better with activity
  • -”stone bruise”
• PE:
  
  • Point tenderness to the underside of the heel
  • -Pain increases with dorsiflexion of toes (stretching of plantar fascia)
  • -Tight calf muscle
• Dx:
  
  • Clinical Dx
• Tx:
  
  • *6-12 months for symptom relief
  • -Conservative: rest, ice, NSAIDs, heel/arch support, PT, night splint (low compliance)
  • -Stretching: eccentric calf stretching, hip flexor stretches
  • -Corticosteroid injections
  • -Surgery reserved for severe cases