Foot/Ankle pathology -Moellmer

Question 1

What are some causes of in-toeing? What is the most common cause and how is it normally treated?

Answer 1

• femoral anteversion
• tibial torsion
• metatarsus adductus
• tibial torsion is the most common

Question 2

How is metatarsus adductus normally treated?

Answer 2

put shoes on opposite feet

full leg cast

Question 3

How will a shin splint and a stress fracture present different clinically?

Answer 3

if touch and generalized pain–> shin splint

If one place touched and a lot of pain–> stress fracture

Question 4

What are shin splints (medial tibial stress syndrome)?

Answer 4

pain or discomfort in the leg from repetitive running on hard surfaces or forcible, excessive use of the foot flexors; diagnosis should be limited to musculotendinous inflammations, excluding fracture or ischemic disorder

-subperiosteal avulsions cause myofascial inflammation

Question 5

What are most ankle injuries from?

Answer 5

inversions (85%)

Question 6

What are the ottawa ankle rules?

Answer 6

Order ankle radiographs if:

• Pain in malleolar region
• Bone tenderness at tip or posterior edge of either malleolus
• Unable to bear weight 4 steps

Question 7

How should a lateral ankle injury be treated?

Answer 7

• early mobilization (don’t want adhesions to form)
• RICE
• pain control–> NSAIDS

Question 8

What is normally the cause of heel pain in adults? in adolescents?

Answer 8

plantar fasciitis in adults

Sever’s Apophysitis (traction apophysitis of the posterior calcaneal physis) in kids
(will present with pain with medial and lateral compression)

Question 9

What are the other causes of heel pain? (TIN MAN VC)

Answer 9

Trauma
Infection/osteomyelitis
Neurologic

Mechanical
Arthritis
Neoplastic

Vascular
Cutaneous

Question 10

What is the necessary tool for diagnosing LisFranc?

Answer 10

weight bearing X-ray

Question 11

What is LisFranc? How will it present in a weight bearing X-ray?

Answer 11

• fracture and dorsal ligament tear
• Top of foot swollen and painful with bruising on the bottom of the foot often from a low energy injury (twist) or a direct trauma)
• -> stirrup injury
• Pain with standing or walking, crutches are required
• dorsal displacement on a weight bearing x-ray

Question 12

How is LisFranc treated?

Answer 12

• cast 8 weeks, non-weight bearing
• surgery
• serial X-rays

Question 13

How does Charcot Neuroarthropathy normally present? what are the 4 stages?

Answer 13

breakdown of the bone!

1. increase blood flow
2. neuropathic–> increase trauma

Acute/Stage 0: hot, normal xray (looks like an infection without hx )

Coalescence/Stage 1: fragmentation, bone resorption, dislocation, fractures

Consolidation/Stage 2: coalescence, sclerosis, fracture healing, debris resorption

Remodeling/Stage 3

Question 14

What should you NOT give to a pt with Charcot?

Answer 14

antibiotics!!!

Question 15

what are good diagnostic tests for Charcot?

Answer 15

• Xray
• MRI–> show increase in metabolism from bone breakdown
• triphasic bone scan

Question 16

Pt presents with “CC: Red, Hot Foot since last week”
Hx:
Known duration of diabetes > 10 years
Seemingly trivial trauma or unknown trauma
Noted change in foot shape (wider or flatter)
“crunching” sensation as walking
Rapid onset of swelling
Increase in temperature of foot
Possibly pain/discomfort

what is the likely diagnosis?

Answer 16

Charcot

Question 17

Where is the Sural N. located?

Answer 17

a thumb’s distance distal to the lateral malleolus

Question 18

What is a 5th metatarsal stress fracture due to? What is the best imaging to diagnose this?

Answer 18

Partial or complete fracture of bone due to its inability to withstand non-violent, rhythmic, and repetitive demand

MRI=more specific than a bone scan and won’t appear on x-ray for 10-21 days

Question 19

What is the treatment for a 5th metatarsal stress fracture? Why?

Answer 19

surgery–> poor blood flow

and immobilization

Question 20

What normally causes the flattening of the foot arch?

Answer 20

failure of the posterior tibial tendon

can be from posterior tibial tendinitis

Question 21

What are some tests to determine if a pt has a problem with the posterior tibial tendon?

Answer 21

• “too many toes” sign==> stand behind the pt and see the toes from behind—> foot everts and flattens
• single heel lift–> cannot do a single heel lift

pt will also have swelling at the medial ankle

Question 22

What is the treatment for posterior tibial tendinitis?

Answer 22

rest, ice, NSAIDS, decrease high impact activity, cast

surgery if needed
–> conservative tx first

Question 23

How is Charcot treated?

Answer 23

Offload/CROW
Bisphosphonates
Bone Growth Stimulation
Edema Control
Surgical Reconstruction

NOT antibiotics!!