Lower Extremity - Part 2- Exam 2 Flashcards
**What are the Ottawa knee rules to decide whether or not to order knee xrays?
_____ is a primary stabilizer of the knee preventing anterior translation of the tibia in relation to the femur. What are the MOI?
ACL
Sudden deceleration with rotational trauma or hyperextension
aka NON-contact injuries
ACL tear is commonly associated with ______. What are rarely injuried?
meniscal tear
MCL, LCL, or PCL are rarely damaged
What usually happens next after the twisting/hyperextension in an ACL tear?
Sudden pain & giving way of the knee
Audible “pop”
joint effusion
What are the 3 special ACL tear tests?
Lachman
Anterior Drawer
Pivot Shift test
What xrays should you order in an ACL tear? What 2 things can it show? How do you confirm ACL tear dx?
AP, lateral and tunnel views
effusion or avulsion fracture
MRI!!
What is a Segond fracture?
May show an avulsion fracture of the lateral capsular margin of the tibia
What pt population is common to see a tibial eminence fx?
common in patients with open growth plates
How is a tunnel view shot? What body part?
knee
What will joint effusion show up like on a knee xray?
A knee joint effusion appears as well-defined rounded homogeneous soft tissue density within the suprapatellar recess on a lateral radiograph
What am I?
Tibial Eminence Fracture with ACL Tear
What is the initial management for an ACL tear?
RICE with knee immobilizer brace, +/- crutches
Pain relief → acetaminophen before NSAIDs
Consider aspiration if effusion is large
Start early ROM exercises as pain allows
When should you refer to ortho for an ACL tear?
Young patients → reconstruction with graft
What is the ACL reconstruction graft made out of?
Graft is taken from patients patellar, hamstring, or quadriceps tendon or from a cadaver
What is the tx for older patients with an ACL tear?
refer to PT to strengthen surrounding muscles to improve stability
What are the MOI for a PCL tear? What is it associated with?
Direct blow to the tibia
extreme hyperextension (usually also has an ACL rupture)
Often associated with other injuries! Collateral ligaments, ACL ruptures
Need to assess ____ if multi-ligamentous injury is suspected. How do you assess it?
NV status
Assess with ABI - if < 0.9 order arterial imaging to r/o intimal tear that could lead to thrombosis
What is the initial tx for a PCL tear? When should you begin ROM?
RICE, Knee immobilizer
Begin ROM after 1-5 days
What is the tx for isolated PCL injuries? What is the tx for multi-ligamentous injuries?
PT to strengthen quads and hamstrings and restore ROM
If PT fails to restore stability reconstruction is needed
Multi-ligamentous injuries → Reconstruction
What is the MOI for a MCL tear?
lateral (valgus) blow to the knee
What is the MOI for a LCL injury?
usually occurs in association with other traumatic knee injuries
Is MCL or LCL more common?
MCL is more common!!
What is the presentation of a collateral ligament tear? When does it get worse? Will the pt be able to bear weight?
Localized pain, tenderness, swelling and stiffness along ligament course
worsens over 6-8 hours
YES!! but it will be very uncomfortable
**What should be included as part of your PE in a collateral ligament injury? What can screw the results?
Varus/valgus testing performed in extension and 30° flexion
Instability may be masked by pain and involuntary muscle contraction
What diagnostic test should you order for a collateral ligament injury? ___ to confirm
AP/lateral knee: to asses for avulsion fracture
MRI to confirm
What is the tx for grade I and II collateral ligament tears?
RICE, hinged knee brace, NSAIDs
Early ROM exercises
Crutches with weight-bearing as tolerated but keep weight off for a few days
What is the tx for a grade III collateral ligament tear?
refer to ortho!!
Conservative (hinged knee brace) vs. repair or reconstruction
_____ is a gel-like pads that sit between the femur and tibia. What is the function?
menisci
Function as shock absorbers and provides a smooth gliding surface during ambulation
What is the MOI for a meniscal injury? What about for older pts?
Rotational force of the knee while foot is planted
Older patients (degenerative tear)
Minimal (squatting down) to no trauma
Pain and stiffness following MOI that progressively worsens over 2-3 days
Ambulation after injury is possible
Patient may report hearing a “pop” at the time of injury
(+) Locking, catching, or popping noted more after effusion begins to resolve
Tenderness along joint line
What am I?
Which one is MC?
meniscal injury
medial meniscus is more commonly affected
When are larger effusions seen more in meniscal injuries? What PE test?
Larger effusion seen in more LATERAL tears (closer to joint capsule)
(+) McMurray - painful click noted on exam
What xrays should you order for a meniscal tear? What does the _____ tell you?
AP and lateral
Add a weight bearing AP with knee in 45° flexion if > 40 y/o
Provides information on amount of osteoarthritis which directly affects surgical outcomes
_____ is the most sensitive diagnostic test for a meniscal injury?
MRI of the knee
should also take weight bearing xrays
What is the initial management of a meniscal injury?
RICE and NSAIDs
What are the meniscal injury indications for an ortho referral for arthroscopic repair? ______ if not having sx
Young patients with traumatic tear
Failure to conservative therapy (persistent joint line tenderness)
Mechanical symptoms
Evidence of ligamentous instability
no going to sx -> then send to PT
knee dislocations are MC in ____. What are the common MOI? What is the MC type of dislocaiton?
young males
severe ligamentous disruption, think higher trauma
Anterior- 40% then posterior 33%
How are knee dislocations characterized?
Characterized based upon direction of the TIBIA in relation to the FEMUR
What % of knee dislocations will spontaneously reduce?
50% will spontaneously reduce
Ecchymosis and swelling
Obvious knee deformity with severe pain and limited ROM
What am I?
What does hyperextension > 30 degrees when the leg is lifted by the foot indicate?
knee dislocation
Hyperextension >30° when leg is lifted by the foot indicates gross instability
What structures are commonly damaged with a knee dislocation? What can happen even with normal pulses?
Popliteal artery, common peroneal and tibial nerve injuries
Limb-threatening vascular injuries are common even with normal pulses
What diagnostics should you order for a knee dislocation?
XR: AP and lateral at initial assessment and post reduction films
CT: assess occult fracture
MRI: to assess soft tissue
What am I?
anterior dislocation
What are the steps for a knee reduction?
SEDATION!!
longitudial traction
post-reduction NV check and xrays
If distal pulses are intact assess vascular integrity by ABI or angiography
Immobilize the knee in 20° flexion
ortho/vascular sx consults
admit for serial NV checks
**Why is it important to immobilize the knee after an knee reduction?
must be immobilized at 20 degrees flexion to help keep the muscles relaxed!!
What is the MOI for a tibial plateau fracture? What is the MC one?
Valgus stress = lateral plateau fracture (MC)
think high energy trauma in a young pt and low-energy in an elderly person (twisting or falling)
What are the complications of conservative management for an ACL tear?
medial meniscus tear and secondary degenerative joint dz
What are the complications of a PCL tear?
osteoarthritis
What will the pt present like for a tibial plateau fracture?
Sudden onset of pain after trauma with the inability to bear weight
Swelling, joint effusion with limited ROM
may have a deformity
What diagnostics should you order in a tibial plateau fracture?
AP, lateral and oblique views
CT/MRI: Evaluate amount of displacement prior to surgical repair
What is a good sign in a tibial plateau fracture?
Beneficial if AP/lateral are inconclusive
aka the fx is not very large
What is the initial management for a tibial plateau fracture? What are the indications for an emergent consultation?
Compression, ice, analgesics, splinting in extension
Open fx, NV compromise, compartment syndrome
What are the urgent consultation indications for a tibial plateau fx?
Fractures with any displacement or depression
Most all fractures will require ORIF
What is the management plan for a non-displaced tibial plateau fx?
Long-leg posterior splint or knee immobilizer, crutches, strict non-weight bearing
F/u with ortho within 1 week
non-weight bearing is important!!
What is the MOI for a tibial tubercle fx?
Sudden force to the flexed knee with quadriceps contracted
Knee flexion at the beginning of a jump or an awkward landing
What pt population are tibial tubercle fx common in?
children!! due to open growth plates
Pain, tenderness, and swelling over tibial tuberosity
loss of ROM
What am I?
What direction will the patella displace?
tibial tubercle fx
displace superiorly
What is the tx for a tibial tubercle fx with an incomplete or small avulsion? Refer to ortho within _____
RICE
Knee immobilizer, long leg posterior splint, no weight bearing
Refer to ortho within 1 week
What is the tx for a tibial tubercle fx with a complete avulsion? Refer to ortho within _____
RICE
Knee immobilizer, long leg posterior splint, no weight bearing
Urgent ortho consult for ORIF (24-48 h)!!!
_____ is the MC long bone fx. Often associated with ______
Tibial Shaft Fracture
fibular fracture
What is the MOI for a tibial shaft fx in adults? children?
Adults: high-energy direct blow to the tibia
Children: twisting injury
What are 3 common complications for a tibial shaft fx?
open fx
NV compromise
compartment syndrome
What dx tests should you order in a tibial shaft fx? ____ if concerned for occult fx
AP, Lateral and oblique Tibia/Fibula XR
knee and ankle xray
bone scan
CT if operative planning
What is the initial management for a tibial shaft fx? _____ is a new emergent consultation indications for a tibial shaft fx
RICE, analgesics, long leg posterior splint
if the fib is also involved: tib/fib fx
What is the tx for a displaced tib shaft fx?
Closed reduction and long leg splinting (posterior + stirrup)
ADMIT for observation and monitoring of complications
Consult ortho
What is the tx for a non-displaced tib shaft fx?
Long-leg posterior splint, crutches, strict non-weight bearing
F/u with ortho within 1 week
What am I? How far up the leg should it go?
stirrup splint
2 inches below the fibular head to avoid peroneal nerve compression
_____ isolated fx are uncommon. What is the MOI?
isolated fibula fx
direct blow or rotational force
Are the pts able to bear weight in an isolated fibula fx?
YES! if isolated
**What is an Maisonneuve fracture?
Proximal fibula fracture with associated medial malleolus fx or ligament disruption of the ankle without fx
What diagnostics are needed in a fibula fracture?
tib/fib: AP and lateral
knee and ankle
What is the initial management of a fibula fx?
RICE, analgesics, long leg posterior splint
What is the tx for a displaced fibula or Maisonneuve fracture?
Posterior long leg splint
Refer to ortho within 24-48 hours
What is the tx for fibular head/neck fx?
Knee immobilizer splint or long leg posterior
Ortho within 1 week
What is the tx for a distal fibula fx?
Stirrup splint or air-cast splint
Ortho within 1 week
What is the tx for an isolated, non-displaced fibular fx?
may begin early weight bearing using crutches as needed
How do you properly assess heel alignment?
while standing and looking from the posterior view
Normal is neutral or slight valgus (turned-out heel) with no more than one or two lateral toes visible from behind
What are the 4 different phases of gait?
Heel strike, mid stance, toe-off, swing phase
What are the normal range of motion for the ankle, foot and toes? What is the starting position?
Starting position - the foot is perpendicular to the tibia
How do you test posterior tibialis muscle?
Resist as patient inverts and plantar flexes
How do you test anterior tibialis muscle?
Resist as patient inverts and dorsiflexes the foot
How do you test peroneus longus and brevis muscle?
Resist eversion
How do you test extensor hallucis longus muscle?
Resist dorsiflexion of the great toe
How do you test flexor hallucis longus?
Resist plantar flexion of the great toe
How do you perform the anterior drawer test of the ankle? What does a positive test indicate?
Excessive anterior translocation of the foot is indicative of anterior talofibular ligament instability
What does the talar tilt test test?
Tests integrity of the calcaneofibular ligament, deltoid ligament, anterior, and posterior talofibular ligaments
What will each of the ligaments tested for in a talar tilt test look like if there is a problem?
Calcaneofibular - inversion from anatomical position
Deltoid - eversion from anatomical position
Anterior talofibular - plantarflexion and inversion
Posterior talofibular ligament - dorsiflexion with inversion and eversion
How do you perform a Thompson test? What does a positive test indicate?
Compression of the calf in a prone position should produce plantar flexion.
Absence of this finding indicates achilles tendon rupture
_____ view of the ankle provides a better view of the ankle joint. What size is normal?
Mortise
gap should be less than 4 mmg
**What are the ottawa ankle rules?
What xray views are included in the foot series?
AP
oblique
lateral
**What are the Ottawa foot rules?
Where does an achilles tendon rupture occur? What are the 2 MOI?
Occurs 5-7 cm from insertion site on calcaneus
Direct (blow) or indirect (forced dorsiflexion - stop and go sports)
aka “feels likes someone hit them” when no one did or forceful step back
Where does an achilles tendon tear occur? What are the MOI?
Occurs at insertion site
Direct (blow) or indirect (forced dorsiflexion - stop and go sports)
Often reports “pop” sound with sudden severe pain
Difficulty bearing weight
Palpable defect
Weak active plantar flexion
(+) Thompson test
What am I?
achilles tendon RUPTURE
How will an achilles tendon injury present?
Less acute/severe pain
Localized tenderness over insertion site
No palpable defect
What imaging should you order for an achilles tendon injury?
ankle xray: to r/o avulsion or other injury
MRI or US to confirm dx
What is the tx for an achilles tendon rupture?
RICE
Short leg posterior splint in slight plantar flexion
Non-weight bearing
Surgical vs non-surgical management
based on pt comorbidities and goals
What is the tx for an achilles tendon tear?
controlled in CAM boot and PT
f/u with ortho in 1 week
What is the MOI for achilles tendonitis?
Microtrauma from repetitive stress in a patient who has increased their training program or is training rigorously for a long period of time
Burning pain and stiffness 2-6 cm above the posterior calcaneus
Worse with activity and relieved with rest
(-) Thompson test
No defect noted
ROM and MS normal
What am I?
What will a long-standing version lead to?
Achilles Tendonitis
in palpable calcaneal spur
Where is the burning pain and stiffness in a achilles tendonitits? What makes it better or worse?
Burning pain and stiffness 2-6 cm above the posterior calcaneus
Worse with activity and relieved with rest
How is achilles tendonitis dx? What is the tx?
clinical dx!
Rest, ice, NSAIDs x 7-10 days
Chronic tendonitis or no improvement with conservative therapy
Refer to PT
What is the MC ankle sprain? from an _____ injury. What ligament is damaged?
Lateral ankle sprain
inversion injury
Damaged to the anterior talofibular ligament or calcaneofibular ligament
_____ is an eversion injury. What ligament is damaged?
medial ankle sprain
deltoid ligament
______ is SEVERE inversion and is damage to the _______
High ankle sprain
tibiofibular syndesmosis
What are the different grades of sprains?
History of fall or twisting injury
Presents with pain, swelling, ecchymosis, difficulty ambulating
Localized point tenderness over involved ligament
Assess both malleoli and 5th metatarsal base
Decreased ROM
What am I?
What 3 PE test should you do?
ankle sprain
squeeze test
+ talar tilt
+ anterior drawer
What is the squeeze test? What does a postive test indicate? When is it used?
Squeeze the tibia and fibula at the mid calf
Pain over the distal tib/fib = damage to tibiofibular syndesmosis
ankle sprains
_____ will be positive in an ankle sprain with anterior talofibular injury
(+) Anterior drawer
What will ankle xrays show in an ankle sprain?
xrays will be normal unless it is a high ankle sprain
What will a high ankle sprain show on xrays?
Tibiofibular syndesmosis widening
What are the 3 phases of ankle sprain management?
phase 1:
RICE with NSAIDs
Aircast splint or ankle brace (rarely a cast for high grade injuries)
Weight bearing as tolerated - crutches if severe pain
phase 2:
start weight bearing at tolerated without pain
continue splint
Start strengthening exercises and achilles stretching
phase 3:
Start once full ROM has returned and strength is up to 80% of normal
Wean ankle bracing
Increased strength exercise intensity
When can you move into phase 2 of management for an ankle sprain? How long does that usually take?
initiate once weight bearing without pain (appx. 2-4 wks after injury)
When can you move on to phase 3 of management in an ankle sprain? How long does that usually take?
Start once full ROM has returned and strength is up to 80% of normal
Approx. 4-6 wks after injury
When should you refer to PT for an ankle sprain?
Refer to PT if limited ROM and pain after 2-3 wks of home therapy
What are the indications to refer to orthro for an ankle sprain?
Nerve injury
hx of chronic instability
failure to improve after 6 wks
What is considered a stable ankle fx? Unstable?
stable: Unilateral fracture without ligament disruption
unstable: Bimaleolar or trimaleolar
What is considered a bilaeolar ankle fx?
Both medial and lateral malleoli fractured
Unilateral malleoli with ligament disruption
What is considered a trimaleolar ankle fx?
Both malleoli with posterior lip of tibia
Both malleoli with ligament disruption
What is the MOI for an ankle fx?
Twisting or fall
In an ankle fx, what do you need to identify?
Identify if point tenderness is only over the malleoli or if ligaments are affected
Palpate proximal fibula for tenderness (Maisonneuve fx)
What diagnostics test should you order for an ankle fx?
ankle xray series: add tib/fib or foot
CT ankle: complex fx before sx
What am I?
bimaleolar fx
bimalleolar fx
What is the tx for an unstable or displaced ankle fx?
Emergent ortho evaluation
ORIF
What is the tx for an unstable, nondisplaced ankle fx? When do you need to f/u with ortho?
Short or long leg splint/cast; non-weight bearing
aka posterior splint
F/u with ortho with in 7 days
What is the tx for a stable ankle fx?
Weight-bearing splint/cast x 4-6 weeks
What is the tx for a suspected occult ankle fx?
Short leg splint and repeat x-ray in 10-14 days
Repeat x-ray in 10-14 days will reveal a bony callus around occult fracture as healing begins
_____ is the MC tarsal bone fx. What is the MOI?
calcaneal fx
Results from axial loading can also have a vertebral fx
How will a calcaneal fx present? What should you do next?
Severe pain in heel with inability to bear weight
Swelling, ecchymosis and deformity may be present
Assess lumbar spine for tenderness
How do you dx a calcaneal fx?
foot and ankle series xr
Lumbar x-ray if (+) exam
CT of ankle/foot if planning sx
What is the tx for a non-displaced calcaneal and talar fx? Displaced fx?
_____ is the 2nd MC tarsal fx . What is the MOI?
Talar Fracture
High force plantarflexion, dorsiflexion or inversion force
What do you need to consider for a talar fx? How will it present?
Extensive blood supply
At risk for avascular necrosis
Severe pain in heel with inability to bear weight
Swelling, ecchymosis and deformity may be present
What is the MC type of ankle dislocation? What is the MOI?
Posterior - MC
Posterior force on a plantar flexed foot
What is the MOI for a lateral displaced ankle dislocation?
Forced inversion, eversion, or external or internal rotation of the ankle
Are ankle dislocations usually stable or unstable? Why?
usually HIGHLY unstable!!
Disruption of the lateral or medial ligaments and/or the tibiofibular syndesmosis
**How will a posterior ankle dislocation present?
Locked in plantar flexion with the anterior tibia easily palpable
If an ankle dislocation presents with vascular compromise, what should you do next?
If vascular compromise is noted, reduction should NOT be delayed for imaging
aka reduce immediately
What is the procedure to reduce an ankle fx?
Procedural sedation
Grasp heel and foot and apply downward traction
Apply posterior leg splint
Reassess NV status
Obtain post reduction films
CONSULT ORTHO IMMEDIATELY
What is the MOI for a metatarsal fx? What is the clinical presentation?
Twisting or rotational force
Blunt trauma (item dropped on foot)
Pain with weight bearing
Swelling, ecchymosis, and tenderness over the fracture site
What is a Jones fx?
Fracture at base of 5th metatarsal = Jones fracture
What is the presentation of a metatarsal stress fx? What is the imaging?
In stress fractures, patients may only demonstrate tenderness on exam
Stress fracture may not be evident in early presentation; repeat films in 2-3 weeks
Consider CT or bone scan if still normal and a suspicion of stress fracture exists
What is the tx for a single nondisplaced metatarsal neck and shaft fracture?
Short leg posterior cast or fracture brace to immobilize the fracture
Weight-bearing is permitted as tolerated
What is the tx for multiple metatarsal fractures or displaced/angulated fractures?
Consult ortho for open or closed reduction
What is a Lisfranc joint? What is it associated with?
Tarsometatarsal Injury
A disruption of the tarsometatarsal joint
often associated with fx of the metatarsals and tarsals
What is the MOI for a Tarsometatarsal Injury?
An axial load placed on a plantar-flexed foot, followed by forcible rotation, bending, or compression
think crush injuries, high-impact accidents such as a motor vehicle accidents, or high-impact sports
What is the presentation of a Tarsometatarsal Injury? **What diagnostics should you order?
Midfoot pain/tenderness
Inability to bear weight
(+) deformity, swelling, ecchymosis
**WEIGHT BEARING foot series
Often bilateral images for comparison
CT/MRI if clinical suspicion but normal x-rays
What is the tx for an non-displaced Tarsometatarsal Injury? For how long?
Non-weight bearing splint/cast (short-leg posterior) x 6-8 wks
Then rigid arch support x 3 months
aka 6 weeks non-weight bearing
What is the tx for a displaced Tarsometatarsal fx/TMT joint?
Non-weight bearing splint/cast (short-leg posterior) x 6-8 wks
Then rigid arch support x 3 months
refer to ortho for ORIF
aka 6 weeks non-weight bearing
What is the MC phalangeal fx? dislocaiton? How do you dx?
MC fracture: 5th phalanx
MC dislocation: MTP of the 1st joint (big toe)
Foot series
What is the tx for a non-displaced phalangeal fx?
buddy tape
What is the tx for a displaced/angulated phalangeal fx?
reduce under local anesthesia and buddy tape
What is the tx for a dislocated phalangeal fx?
digital block with traction reduction
Repeat post reduction films
What is hallux valgus? Describe it. **What sex? What is it caused by?
a bunion
Lateral deviation of the great toe at the metatarsophalangeal (MTP) joint
**10X more common in females
Caused by tight fitting shoes and osteoarthritis
_____ will present like pain and swelling of the 1st MTP joint with normal ROM. How do you dx?
Hallux Valgus
Foot series xray
**The foot series xrays in hallux valgus measures _____ and the ______. What is considered normal?
**Measure valgus angulation at the MTP joint
**Normal is < 15°
What are the non-sx tx options for hallux valgus?
Patient education and shoe wear modifications
Recommend shoes with adequate width at the forefoot, soft material, and stitching patterns over the bunion
Avoid high heels!!
Usually successful in mild to moderate cases
When should you refer to ortho for hallux valgus?
Patients who remain symptomatic with conservative therapy
will need sx when the toes start to overlap
What is Morton’s neuroma? Where is the MC location? What sex?
A perineural fibrosis of the common digital nerve as it passes between the metatarsal heads
Most commonly occurs at the base of the 3rd and 4th toes (3rd web space)
5x more common in females
What will the pt complain about in Morton’s neuroma? What is it likely related to?
“feels like there is a rock in my shoe”
Likely related to compression of the nerve by tight shoes
Plantar pain in the forefoot
Burning in nature
Dysesthesias into the affected two toes
“walking on a marble”
What am I?
What should you do next?
morton’s neuroma
Interdigital Neuroma Test
Describe how to perform a Interdigital Neuroma Test? What is a positive test?
Apply direct plantar pressure to the interspace with one hand and then squeeze the metatarsals together with the other hand
(+) increased tenderness and pain radiating into the toes
What are the tx options for morton’s neuroma?
usually a non-sx options are helpful!!
pt education: Wear low-heeled, well-cushioned shoes with a wide toe box
Application of a metatarsal pad in the sole of the shoe
steroid injection if unresponsive to conservative therapy
can sx excision neuroma or divide the transverse metatarsal ligament if severe/refractory
_____ is one of the most common causes of heel pain in adults. What age range does it peak?
Plantar Fasciitis
Peak incidence between ages 40-60
What are risk factors for plantar fasciitis?
Obesity
flat feet
prolonged standing/jumping
aka an overuse injury
SLOW onset
Heel pain that is worse when initiating walking
Tenderness directly over the medial calcaneal tuberosity and 1 to 2 cm along the ______
What am I?
**When is the pain the most severe?
What causes pain to increase?
plantar fasciitis
**Typically most severe during their 1st steps in the morning or after a long period of inactivity/sitting
Passive dorsiflexion of the toes may cause increased pain
In plantar fasciitis, does the pain tend to get better or worse with walking?
Pain typically lessens with walking and is relieved by sitting
worse at the end of the day due to prolonged weight bearing
Where exactly is the tenderness in plantar fasciitis?
Tenderness directly over the medial calcaneal tuberosity and 1 to 2 cm along the plantar fascia
What is the non-sx tx options for plantar fasciitis? What is the initial tx?
OTC orthotic heel pad and a home stretching program
What is the tx for plantar fasciitis that is unresponsive to conservative therapy?
Corticosteroid into the heel
Custom orthotic
Surgical treatment: consists of partial release of the plantar fascia
