Foot/Ankle Potential Pathologies Flashcards
Foot/Ankle Potential Pathologies
Fx Achilles Tendon Rupture DVT Sprains Instability Strains Plantar Fasciitis Osteochondral Injuries OA Capsular Restrictions Peripheral Nerve injuries Diabetic Foot
Foot fractures common sites
5 Met
Stress fx of the mets
Calcaneus
Foot fx common MOI
overuse or trauma
Stress fx symptoms
swelling
tenderness
gait change
reproduction of cc by performing activity
Special tests stress fx
Metatarsal compression test
Tuning fork
Ottawa Ankle Rule Ankle X-Ray required if
- Pain in anterior aspect of medial or lateral malleoli and anterior talar dome area
- Bone tenderness at posterior medial malleolus
- Bone tenderness at lateral malleolus
- Inability to bear weight on the limb immediately after the injury and in the ER
Ottawa Ankle Rule Foot X-Ray required if
- Pain in dorsal medial and lateral aspect of the midfoot
- Bone tenderness at the base of the 5th metatarsal
- Bone tenderness at navicular
- Inability to bear weight on limb immediately after the injury and in the ER
Metatarsal Compression Test
Morten’s Test
Positive pain with metatarsal fx or neuroma
False positive in pt with metatarsalgia
Unclear evidence to support this
Tuning Fork
For fibular fx
Pt supine, stethoscope is placed on fibular head, hit a tuning fork on lateral malleolus
Positive if there is a different sound in bilateral comparison
Minimal evidence to support it
Achilles Tendon Rupture
MOI: trauma jumping or landing, prolonged steroid use?
Symptoms: “Hit” in the back of the anke, “pop”, weak
Special tests:
-Bilateral Toe Raise
-Thompsons test
Thompson Test
Squeeze gastroc w/ patient in supine, foot should PF
Positive test if nonresponsive ankle PF during test
Unclear evidence to support this
Deep Vein Thrombosis
MOI: Insidious, after recent surgery or immobilization Signs/symptoms -calf pain, ankle swelling -Antalgic gait Special Tests: -Homan's sign -Calf Swelling -Well's CPR for DVT
Homan’s Sign
Positive test is popliteal and/or calf pain
Many presentations may lead to false positive
Minimal evidence to support this
Calf Swelling
Positive test if bilateral comparison is difference of 15 mm for men or 12 mm for women
Minimal evidence to support this
Well’s Clinical Prediction Rule for DVT
Asking questions regarding recent events
Positive test related to score on the test
Strongly supported by evidence
Great for screening and ruling out an ER trip
Ligamentous Injuries
Inversion/Supination: Lateral ligaments
Eversion/Pronation: Deltoid ligaments
Syndesmosis Injuries
Acute Lateral Ankle Sprain
MOI: Trauma Inv/PF Symptoms: -Difficulty in activity -Lateral ankle pain -Medial ankle pain: Kissing lesion -Swelling -Ecchymosis -Painful WB and ROM
Kissing Lesion
Medial aspect compromised because of medial malleolus and talus contact during inversion
Grade I Acute Ankle Sprain
Mild (2 weeks rehab)
-Mild effusion, no hemmorrhage
-Negative anterior drawar, negative varus laxity
-Pain with inversion and PF
Little to no limp, but trouble with hopping
Grade II Acute Ankle Sprain
More swelling, hemmorrhage likely present
Positive anterior drawer, no varus laxity at neutral
Limping with walking, unable to raise on toes/hop/run
Grade III Acute Ankle Sprain
Immobilization 1-10 days, 8-10 weeks of rehab Diffuse swelling, hemmorrhage Significant instability Complete tears of ATFL and CFL Unable to FWB Decreased ROM
Chronic Ankle Sprains
Patient reports giving way with no pain in between inversion episodes
Leads to chronic instability
If ll. are lengthened beyond patients control then surgery is necessary
Anterior Drawer Ankle
Positive test if pain reproduced laterally or excessive gapping betwen the distal lateral malleolus and calcaneous
Longitudinal fibularis tendonitis/subluxation
-Swollen, tender, painful posterior to lateral malleolus
-Pain with AROM eversion
-Minimal response to PT intervention
May seem like lateral ankle sprain
OCD/Loose bodies within joint
Effusion
Crepitus felt when palpating medial/lateral talus
“catch” “lock” “give way”
Can look like lateral ankle sprain
Anteriorlateral synovitis or impingement
No swelling Point tenderness at anteriolateral junction of tib/fib Pain with DF, Increased activity, stairs May look like lateral ankle sprain Use Forced DF test to rule in or out
Talar Tilt
- Positive if pain is reproduced or excessive gapping between the distal lateral malleolus and calcaneous
- DF to bias PTFL, Neutral for CFL, PF for ATFL
Posterior Drawer Test
Positive test if pain is reproduced or excessive gapping between distal lateral malleolus and calcaneus
Eversion Stress Test
- Positive test if pain is reproduced medially over deltoid ligament or excessive compression at lateral aspect between distal lateral malleolus and calcaneus
- For acute medial ankle sprain
Syndesmosis Injuries
MOI: Leg rotation with immobile foot S/S: Pain in anterior distal shin; difficulty ambulating and decreased ROM (DF>PF) Special Tests: -Fibular translation test -Crossed Leg test -Kleiger test
Fibular Translation test
Positive if pain produced with fibular translation and more displacement compared to contralateral side
-Tests for syndesmosis injury
Crossed Leg Test
Positive test if pain produced is chief complaint
Therapist assists by applying gradual pressure w/ test
-Tests for syndesmosis injury
Kleiger Test (ER stress test)
Positive if pain produced is cc.
Unclear evidence to support this test, it may also test medial ligaments.
-Tests for syndesmosis injury
Musculotendinous Injury
MOI: Poor footwear; Tight muscles; Overuse Imbalance
S/S: Pain with active contraction and passive lengthening
Posterior heel Musculotendinous injury
Achilles tendonitis (Insertional v. Non-insertional)
Acute Rupture
Chronic Rupture
Medial Foot musculotendinous injury
Posterior tibialis tendon insufficiency
Non-Insertional Achilles Tendonitis
Above insertion of achilles tendon
MOI: Overuse; increased running intensity; shoe change
Types:
-Paratendonitis
-Tendonosis
-Paratendonitis with tendonosis
S/S:
-may improve w/ mild activity
-Mild ache in posterior leg post activity
-more pain after prolonged activity or stairs
-Tenderness or stiffness, especially in am
-bulbous area mid-tendon
Insertional Achilles Tendonitis
At insertion onto calcaneus
MOI: Overuse, increased running intensity, shoe change
Types:
-Haglund’s Deformity
-Pretendon Bursitis
-Retrocalcaneal Bursitis
S/S:
-may improve w/ mild activity
-Mild ache in posterior leg post activity
-more pain after prolonged activity or stairs
-Tenderness or stiffness, especially in am
-Active inflammation
-Tenderness, swelling over insertion
Paratendonitis
Inflammation of the lining around the tendon
Tendonosis
Noninflammatory, age related degeneration of the tendon itself
Paratendonitis with tendonosis
Paratendon inflammation with infratendinous degeneration
Haglund’s deformity
Enlargement on the back of the heel
Pretendon bursitis
located anterior to the tendon
Retrocalcaneal bursitis
located posterior to the tendon
Achilles Tendonitis special tests
SLS (single leg stance) heel raises
Thompson test
Foot/ankle biomechanical exam
Achilles Tendon Rupture
Age: Typically 30-40 Weekend warrors; explosive activities Medications -Antibiotics -Systemic corticosteroids Palpable defect; severe loss of function
Surgical vs Non surgical Achilles Tendon Rupture
Less risk of re-rupture with non-surgical repair
Non-surgical:
-Immobilized in 20 degrees PF for at least 4 weeks w/ progressive WBAT
Surgical:
-Standard vs accelerated program
-Initially NWB w/ immobilization 4-6 weeks
-Slowly increased WB in CAM boot with DF ROM neutral at 6 weeks
-Accelerated protocol may be earlier WB and Earlier DF Neutral
Posterior Tibialis Tendon Dysfunction/Insufficiency
MOI: Inflammation and degeneration of the tendon progresses to lengthening and mechanical insufficiency S/S: -Acute or gradual onset -pain in medial long arch -secondary pain in lateral hindfoot -pain/weak MMT -hindfoot valgus -medial talar bulge Special Tests: Too many toes sign, No inversion w/ heel raise
PTTI Stage I
S/S: Pain with inversion
Rx: Rest tendon, modalities, walking brace
PTTI Stage II
S/S: History of pain 2-3 years, no rearfoot inversion during unilateral heel raise
Rx: Walking brace 4 weeks and orthotics (6 months)
PTTI Stage III
S/S: Fixed hindfoot deformity (Valgus) with a compensated forefoot, arthrosis of STJ
Rx: Triple arthrodesis (fusion), heel cord lengthening
Plantar Fasciitis
MOI: Direct repetitive microtrauma, pes planus or cavus, increased BMI, prolonged standing, reduced DF ROM
S/S:
-Pain/stiffness in AM and after prolonged sitting
-Recent change in intensity of running
-worse walking barefoot
-point tenderness over medial calcaneal tubercle
Plantar Fasciitis differential diagnosis and treatment
Achilles tendonitis vs peripheral nerve entrapment
Acute
-85% of patients will get better within 10 months
-NSAIDs, DF, night splints, OTC insoles
Chronic
-Repetitive partial tear and chronic irritation
-Patients with symptoms past 10 months need to consider different diagnosis and r/o entrapment symptoms
NWB examination
PROM IR/ER Hip
Tibial Torsion
Subtalar Neutral
Forefoot to rearfoot position
Weight bearing examination
Tibial varum Rearfoot valgus/varus Navicular drop test Forefoot adduction/abduction Bilateral comparison of navicular height (Feiss line)
Osteochondral Injuries
MOI: OCD s/p traumatic ankle sprain Most common in the talus S/S: Pain during terminal stance, decreased standing tolerance, aching during rest Special Tests: -Blind stance ability vs FTPO -Treadmill tolerance test -Step-up tolerance test -Step-down tolerance test -unilateral toe raise tolerance test -balance tests
Non-surgical intervention osteochondral injuries
Period of immobilization and NWB to allow for cartilage to heal
Surgical Invterventions osteochondral injuries
Debridement
Fixation of the injured fragment
Microfraxture or drilling of the lesion
Transfer or grafting of bone and cartilage
Rheumatoid Arthritis
Inflammation of the joint capsule
Will often affect the metatarsals and digits
Gout
Excessive amounts of uric acid
Often affects the great toe
Osteoarthritis
Degenerative
- Redness, inflammation, swelling
- Pain and stiffness particularly in the morning or after rest
- OA progresses more rapidly due to previous joint injury
Osteoarthritis Criteria for diagnosis
Age >50 Stiffness >30 minutes Crepitus Bony tenderness Bony enlargement No palpable warmth
Capsular Restriction
MOI: Post ankle immobilization, develops over time Presentation -Capsular pattern during AROM/PROM TC pattern PF>DF 1st MTP pattern DF>PF
Tarsal Tunnel Syndrome
MOI: Insidious, RA S/S: -Difficulty localizing pain, diffuse burning, worse at night Special tests: -Tinel's sign at the tarsal tunnel
Distal Tarsal Tunnel Syndrome
Baxter's nerve: lateral plantar nerve Population 40-50 y/o MOI: >9 month hx of plantar fascia type pain, long distance runners S/S -Pain at medial calcaneal tubercle -Decreased sensation at lateral heel -Unable to abduct 5th digit
Diabetic Peripheral neuropathy
Neuropathic Ulcers
Diabetic Charcot neuropathy
Osteomyelitis
Charcot Neuropathic Fractures and dislocations
Diabetic Foot
Prevention is the best treatment
- Daily foot inspections
- Appropriate footwear
- Custom diabetic inserts
SLR Nerve biases
Tibial nerve bias: DF, eversion
Fibular nerve bias: PF Inversion
Sural nerve bias: DF, Inversion
