Foot & Ankle Disorders Flashcards
History
Inciting injuries, specific location of pain, functional impairment, chronicity of sx, exacerbating conditions; medical hx including DM, arthropathies, vascular disease, neuropathy
Exam
Asses gait, ability to toe rise; look at ankle alignment from behind; assess hindfoot alignment and arch (cavus vs neutral vs planus); visually inspect pedal skin and nails for soft tissue breakdown or asymmetry in color, temp, texture; palpate foot for areas of tenderness, masses or swelling; assess active ROM, including tibialis anterior (ankle dorsiflexion), gastrocsoleus (plantarflexion), inversion w/the foot plantar-flexed (posterior tibialis), eversion w/the foot dorsiflexed (peroneal); gentle passive ROM of ankle (tibiotalar joints), subtalar joint, transverse tarsal joint, Lisfranc joint (plantarflexion of 1st metatarsal and adduction), & MTP joints; palpate pulses (dorsalis pedis and posterior tibial) and capillary refill; test reflexes and sensation to light tought and pinprick.
Imaging
Radiograph of ankle should include AP, lateral, mortise; Radiograph of feet should include AP, lateral, oblique, and wt bearing views (default unless assessing for fracture or pt unable to bear weight); stress fracture may take 2-6 weeks to be apparent on radiographs; MRI more sensitive.
Ottawa rules: Ankle radiograph for ankle injury if:
Pain near malleoli + either (1) inability to bear wt (4 steps) immediately after injury & at eval or (2) bone tenderness at posterior edge/tip of either malleolus
Ottowa rules: Foot radiograph for foot injury if:
Pain at midfoot + either (1) inability to bear wt (4 steps) immediately after injury and at eval or (2) bone tenderness at navicular bone or base of 5th metatarsal (se nearly 100%, sp 30-50%)
Atraumatic Foot Pain
Calcaneal bursitis Hallux rigidus Morton neuroma Plantar fasciitis Cysts/Ganglions Bunions Pes Planus Plantar fibromatosis
Calcaneal bursitis
Infra- of retrocalcaneal pain in SC or subtendinous bursa;
Dx: tenderness and swelling, pain w/supracalcaneal squeeze
DDx: achilles tendinopathy
Tx: time, NSAIDs, ice
Hallux Rigidus
OA of the 1st MTP joint
Dx: Sx include decrease motion, crepitation, tenderness, readiographs
Tx: Nonspecific; stiff sole or rocker sole shoe
Morton (interdigital) neuroma
Irritation of digital nerve usually in 3rd or 4th web space; burning pain in webspace +/- numbness of digits
Dx: Reproduction of sx w/pressure in the web space; mulder click-palpable click between metatarsal heads elicited by compressing forefoot
Ddx: stress x
Tx: podiatry referral for orthotics and steroid injection in refractory cases
Plantar Fasciitis
Medial/plantar heel/arch pain increases in AM and w/standing after prolonged siting, appears to be self-limiting enthesopathy
Plantar Fasciitis
Risk Factors
Pts often middle-aged; specific risk factors include female gender, obesity, tight gastrocnemius, and prolonged wt bearing at work
Plantar Fasciitis
Dx
Tenderness of plantar fascia originates from calcaneus
Plantar Fasciitis
Ddx
Tibial nerve compression (tinel sign behind medial malleolus), bursitis at Achilles insertion, calcaneal stress fracture(squeeze test), heel pad pain (pain more posteriorly at center of heel pad), posterior tibial tendinitis (palpate tendon behind medial malleolus)
Plantar Fasciitis
Tx
NSAIDs, ice, heel cord stretching and plantar fascia stretches, silicone gel heel cups; steroid injection in refractory cases may be considered; wt loss.
Cysts/Ganglions
Pain w weight bearing, friction,
Dx: clinical, U/S, MRI
Tx: surgery for off-loading, aspiration, excision if painful.
Bunions
1st MTP joint w/medial prominence; pain onset gradual, progressive, increases w/ROM, weight bearing, shoe pressur; a/w RA, OA, DM, neuropathy, increase age, FHx, footwear, running
Bunions
Tx
Footwear modification, bunion shield, surgical correction only for refractory pain or deformity severe enough to prevent nl shoewear (ie not for cosmesis); APAP for pain relief
Pes planus (flat foot) or Pes cavus (high arch)
dx
Clinical, plain fimls; varied adult presentations; cavus often assoc w/neuromuscular disease; planus assoc w/medial ankle pain -> suspect adult-acquired flat foot 2/2 posterior tibialis pathology
Pes planus (flat foot) or Pes cavus (high arch)
Tx
Off-the-shelf orthotic w/medial arch support; otherwise referral for footwear modification, orthoses, bracing, surgical correction
Plantar fibromatosis
Foot manifestation of Dupuytren disease; genetic (autosomal dominant; British Isles and Scandinavia); firm, palpable SC plantar nodules, continuous w/plantar fascia; pts often p/w pain, but lesions not typically painful; most pts do not binrg this problem to the attendion of a dr
Tx: nonspecific and palliative
Skin and nail disorders
Hyperkeratotic Verruca Blisters Tinea pedis (Athlete's foot) Xerosis cutis Ingrown nail Onychodystrophy Onychomycosis Paronychia Nail contusion
Hyperkeratotic
Pressure induced (corns) vs shear induced (calluses); assoc w/neuropathy, deformity, activity, middle to advanced age
Hyperkeratotic
Ddx
Verruca plantaris, dermatofibroma, hypertrophic scar, prokeratosis
Hyperkeratotic
Tx
Topical keratolytics (lactic acid 12% lotion, urea 20-40% cream, footwear modification)
Verruca
Virally-induced (HPV) hyperkeratotic lesions w/punctate bleeding, disrupted skin lines, pain w/compression: increase in youth, immunosuppressed, skin trauma, gym/pool use
Verruca
Tx
topical acids/vesicants
Blisters
Serous/blood filled vesicles/bullae; increase w/friction, shear, deformity, activity, tight shoes, hyperhidrosis, neuropathy
Blisters
Tx
Neoprene insoles, acrylic socks, off-loading, aspiration (do not deroof); if derooted, hydrocolloid dressing.
Tinea pedis (athlete’s foot)
Rubor, scaling, desiccated vesicles, moccasin distribution, maceration fissuring, pustules, malodor
Dx: +KOH
Ddx: Eczema, xerosis, dermatitis
Tx: topical antifungal
Xerosis Cutis
Skin dry, rough, pruritic, fissuring; increase with age, DM, autonomic dysregulation
Tx: topical emollients, barrier creams; discourage prolonged frequent or hot foot soaks
Ingrown Nail (onychocryptosis)
Nail plate encroaching uon nail fold w/pain, welling, bleeding/drainage, hypertrophy of nail fold +/- paronychia; assoc with/HAV, tight footwear, improper trimming
Tx: foot soaks, wide shoe, podiatry referral
Onychodystrophy
Change in nail plate morphology +/- pain; increase w/age, DM, runners
Hutchinson sing: Brown/black pigmentation of nail assoc w/melanoma
Onychomycosis
Fungal nail infection; onychodystrophy + nail erosion; increase w/DM, immunocompromised, incrase age, nail, salon use, trauma, tinea pedis
Dx: +KOH, +PAS
Tx: podiatrly referral, antifungal tincture (ciclopirox), PO terbinafine (check LFTS)
Paronychia
Nail fold infection a/w onychocryptosis; erythema, warmth, edema, purulent d/c, pain
Tx: Saline soaks, BID, topical antiseptic, consider oral abx, prompt podiatry referral
Nail contusion
Subungual hematoma/seroma s/p stubbing or crush injury; if pain in toe, obtain plain film
DDx: glomus tumor (benign subungual vascular lesion)
Tx: If no fracture, podiatry referral; if fracture + nail bed laceration, podiatry/ortho referral.
Foot and Ankle Trauma
Achilles tendon rupture
Fractures
Lisfranc dislocation
Plantar plate injury (turf toe)
Achilles Tendon rupture
Popping and sudden onset of pain -> instability
Dx: Ecchymosis and palpable deficit posterior ankle, Thompson test + (no plantarflexion of foot w/calf squeeze), MRI, U/S.
Tx: Referall to ortho, in the interim splint in 20degrees of plantar flexion (not neutral); brief cast immobilization followed by achilles rehab protocols; surgery
Fractures
high index of suspicion if pain onset acute, pt w/DM, increase age, osteopenia, neuropathy, hx Fx, smoking, +/- trauma
Dx: Tenderness, edema, ecchymosis, pain, plain films (if negative, presume stress Fx)
Metatarsal fx
5th metatarsal tuberosity avulsion Fx occur w/inversion of foot/ankle while in plantar flexion or inversion -> pt may report sprained ankle; acute and stress diaphyseal Fx also occur, w/stress Fx frequently only visible on radiography once healing creates bony callus; Ortho referral for 1st metatarsa, multiple, displaced, stress Fx of proximal diaphysis of 5th metatarsal, or intraarticular Fx; O/w, splint, progressive wt bearing (often in hardsole shoe), ide, elevation
Sesamoid fx
Pain under 1st MTP joint
Calcaneus fx
Pain s/p fall/jump; pain w/lateral squeeze, Mondor sign (ecchymosis extending to sole); stress Fx may present like plantar fasciitis, however unlike plantar fasciitis, tenderness on sides of calcaneus present
toes Fx
Ortho/podiatry referral for great toe Fx, circulatory compromise, displaced intraarticular or irreducicle Fx
Fx Tx
Cast or boot, buddy toe taping X 4-6 weeks for lesser toe fractures; if intra-articular, comminuted, displaced >3mm, urgent podiatry/ortho referral
Lisfranc dislocation
High energy insult -> damage to Lisfranc ligaments (maintain relationship between forefoot and midfoot) -> midfoot pain/swelling; must have high index of suspicion and cannot r/o unless have wt-bearing radiographs (may only displace w/wt bearing0: if pt unable to wt bear, repeat radiographs in 2 wks when pt able to wt bear
Lisfranc dislocation
Dx
Midfoot diastasis, 2nd metatarsal step off, fleck sign (bony fragment at base of 2nd metatarsal), +/s metatarsal fx on plain films, CT, MRI
Lisfranc dislocation
Tx
Jones dressing, posterior splint, emergent orthopedic eval
Plantar plate injury
Turf Toe
Dorsiflexion injury causing attenuation of 1st MTP joint plantar plate w/pain, swelling, ecchymosis
Ddx: gout, sesamoid injury, cellulitis
Dx: clinical, arthrogram
Tx: cast or boot, podiatry/orthopedic referral
Ankle Pain
Achilles tendonitis
Ankle sprain
Ankle fracture
Ankle tendonitis
Pain w/exercise, relieved by rest, morning stiffness; pain w/passive rotation of ankle; MRI may aid dx
Tx: Rest, ice, APAP, orthotics, PT
Ankle Sprain
Limited wt bearing, early mobilization, range of motion exercises, ice, compression (ace wrap), elevation, NSAIDs
Ankle fracture
Fx that are stable and can be managed nonoperatively w/splinting, ice, elevation, analgesics include completely nondisplaced fractures where the talus remains perfectly seated within the ankle mortise
