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CUCC > MSK Lower Leg, Ankle, & Foot > Flashcards

MSK Lower Leg, Ankle, & Foot Flashcards

1
Q

Name the components in the anterior compartment of the leg: 7

A

Muscles:

  • Tibialis anterior (DF/Inversion) (L4/5)
  • Extensor HallicusLongus (DF/Inversion) (L4/5/S1)
  • Extensor Digitorum (DF/Eversion) (L5/S1)
  • Peroneus tertius (DF/Eversion) (L5/S1)

Nerve - Deep peroneal nerve (L4/5/S1)
Anterior tibial artery and vein

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2
Q

Name the components of the lateral compartment of the leg: 3

A

Muscles:

  • Peroneus brevis (everter/weak PF)
  • Peroneus longus (Everter/weak PF)

Nerve - superficial peroneal nerve - L5/S1
(here the common peroneal nerve divides into the superficial and deep branches.

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3
Q

Name the components of the deep and superficial posterior compartment of the leg

A

Deep posterior compartment:

  • Flexor digitorum longus (Flexion of lateral 4 toes, Inversion, PF: Tib L5-S2)
  • Flexor Hallucis longus (Tib S2-3)
  • Tibialis posterior (inversion/PF: Tib L5-S2)
  • popliteus muscle (IR of leg on femur: Tib L5-S2)
  • Nerve: Tibial nerve
  • Posterior tib artery and vein

Superficial posterior compartent:

  • Gastrocnemius (PF - tib L5-S2)
  • Soleus (PF: Tib - L5-S2)
  • Plantaris (weak PF: Tib - L5-S2)
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4
Q

____ is a condition marked by chronically raised intracompartmental pressure.

what is the source of pain in this condition

A

Chronic exertional compartment syndrome (CECS)

Pain could be due to tissue ischemia due to restricted arterial inflow, obstruction of microcirculation, or arteriolar or venous collapse. Also could be sensory receptor stimulation in fascia or periosteum caused by high pressure; or the release of biochemical factors caused by reduced blood flow.

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5
Q

In CECS (Chronic exertional compartment syndrome) pain will usually occur with ____

A

exercise and progress as the activity increases in intensity. Pain diminishes after activity is stopped.

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6
Q

Name presentations of the varius CECS (chronic external compartment syndromes):

  1. Anterior
  2. Lateral
  3. Deep posterior
A
  1. dorsiflexor weakness, numbness over the first web space of the dorsum of the foot - deep peroneal nerve)
  2. dorsiflexor weakness and first web space numbness (deep peroneal nerve) or foot evertor weakness and numbness of the dorsal foot and anterolateral distal shin
  3. cramping of the foot intrinsics and numbness of the medial arch of the foot (tibial nerve)
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7
Q

In chronic exertional compartment syndrome (CECS), discuss a positive test when measuring compartment pressure

A

manometric techniques are best means. Elevated pressures should coincide with reproduction of the exact pain syndrome.

pressures are measured pre-and post exercise. A delay in return to pre-exercise pressure levels of 6-30 mins is required for a positive test.

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8
Q

In acute compartment syndrome, necrosis of muscle and nerve tissue can develop in as little _______

A

4-8 hours

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9
Q

Which two areas of the body are most commonly affected by acute compartment syndrome

A

volar aspect of the forearm

anterior compartment of the leg

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10
Q

describe sequelae of untreated compartment syndrome: 4

A
  1. tissue necrosis
  2. secondary muscle paralysis
  3. muscle contractures
  4. sensory impairment - Volkmann’s ischemic necrosis

results in claw hand or foot caused by contractures

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11
Q

What is the sensory impairment called in acute compartment syndrome

A

Volkmanns ischemic necrosis.

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12
Q

First symptoms in acute compartment syndrome:

What are the 3 Ps of this?

A

Intractable pain, and sometimes sensory hypesthesia distal tothe involved compartment (usually top of the foot and median distribution of the hand)

Pain, Paresthesia, paralysis

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13
Q

In acute compartment syndrome, after cast removal, what is the most important physical sign?

A

extreme pain with stretching of the long muscles passing through a compartment.

NOTE: pulses are usually completely normal in ACS because of intracompartmental pressure rarely exceeding systolic or MAP.

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14
Q

General guidelines for acute compartment syndrome (ACS) and manometry is:

A

the presence of compartment syndrome when the diastolic pressure minus the intracompartmental pressure is < or = 20mmHg

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15
Q

____, also known as shin splints, is a common cause of exercise-induced leg pain. Etiology?

A

Medial tibial stress syndrome (MTSS)

results from chronic traction on the periosteum at the periosteal-fascial junction. The periosteum may be come detached from the bone due to ballistic overload. Fibrofatty filling may occur at the site of the defect.

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16
Q

What is the major predisposing factor for medial tibial stress syndrome (MTSS)?

A

hyperpronation

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17
Q

_____ occur when repetitive loading causes irreversible bone deformation. These develop with continued overuse they can coalesce and propagate through the bone to become symptomatic

A

Stress fractures.

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18
Q

Low bone mineral density impose a higher risk for stress fractures. causes of low BMD? 4

A
  • females with late onset menses
  • individuals with low body weight (<75% ideal body weight)
  • Poor nutrition correlates with lower calcium intake
  • tobacco and alcohol use
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19
Q

Biomechanical conditions can lead to higher risk of stress fractures: 2

A
  • over pronation places higher stress on fibula and tibia (genu valgum and a wide gait pattern may cause over-pronation)
  • Leg length discrepancies
  • muscle imbalances
  • lack of flexibility
  • malalignment factors can also place high forces on the lower leg.

External factors: classic training errors of increasing intensity and length of activity abruptly or causing excessive fatigue; also running on hard surfaces or using worn-out shoes

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20
Q

Top three sites of LE stress fractures in runners

A

34% Tibia
24% Fibular
20% Metatarsals (2nd > 3rd > other)

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21
Q

deliniate the progression of stress fractures appearance on XR as time progresses

A
  1. May not be seen for 2-3 weeks after symptoms develop
  2. Periosteal thickening appears first
  3. cortical lucency
  4. Linear stress fracture appears as a lucency within a thickened area of cortical hyperostosis during healing.

** bone scans are used when radiographs are negative and stress fracture is highly suspected. (100% sensitive but low in specificity)

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22
Q

When will a bone scan turn positive in stress fractures?

A

third phase

  • tumors, osteomyelitis, bony infarct, bony dysplasias can also cause localized increased uptake.

MRI is becoming the first-choice means of investigating stress fractures.

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23
Q

Treatment of stress fractures.

  1. If pain on normal ambulation:
  2. ____ can begin immediately.
  3. ____ activities can be used to maintain cardiac fitness.
  4. Atleast _____ of pain free normal ambulation should be achieved before returning to impact activity.
  5. Supplement?
A
  1. NWB for 7-10 days
  2. NSAIDs, ICE, muscle strengthening and stretching.
  3. Non impact activities such as cycling and swimming
  4. 1-2 weeks
  5. 1500mg QD calcium with 400-800 IU of Vit D

Impact activity is started cautiously at low intensity for short periods (10-15 mins) in the first few days and increased incrementally as tolerated.

Orthotics are useful adjunct to tx and may decrease impact force and help correct excessive supination or pronation.
Softer running surfaces should be considered.

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24
Q

Describe the components of the ankle mortise

A
  1. Distal tibia - makes up medial malleolus and the superior articular surface of the ankle mortise joint.
  2. Distal fibula - forms the lateral malleolus and the superior articular surface of the ankle mortise joint
    - lateral mall extends more distally than the medial mall, making it very important in ankle stabilization.
  3. Talus (4 parts)
    - body
    - neck
    - head
    - dome
    It has a fragile blood suppl, which can lead to complications of healing.
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25
Q

Name the bones of the foot: How many?

A

28

7 Tarsals - Talus, calcaneus, navicular, cuboid, 3 cuneiforms (medial, intermediate, and lateral)

5 metatarsals

14 phalanges (proximal, middle, distal - the great toe only has proximal and distal phalanges)

2 sesamoid bones (located on the plantar surface of the head of the first metatarsal)

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26
Q

Which ligaments make up the lateral aspect of the ankle 3

A
  1. Anterior talofibular ligament - primary lateral ankle ligament stabilizer; most commonly injured ligament
  2. Calcaneofibular ligament (CFL)
  3. Posterior talofibular ligament (PTFL)
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27
Q

Which ligaments make up the medial aspect of the ankle?
Main ligament?
Deep and superficial

A

The deltoid ligament stabilizes the medial ankle joint and is stronger than the lateral ligaments.

Deep: (more important for stabilization)

  • Anterior tibiotalar
  • Posterior tibiotalar

Superficial

  • Tibionavicular
  • tibiocalcaneal
  • Spring ligament (posterior calcaneonavicular ligament)
  • Medial and posterior talocalcaneal ligaments
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28
Q

Importance of deltoid ligament

A

Deltoid ligament maintains close proximity of the medial mall and talus preserving the medial longitudinal arch of the foot.

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29
Q

Name the ligaments of the anterior aspect of the ankle joint 4

A

Comprised of 4 ligaments that maintain the integrity of the distal tibia and fibula as well as resisting any forces that would separate the 2 bones.

  • Anterior tibiofibular ligament
  • Posterior tibiofibular ligament
  • Transverse tibiofibular ligament
  • Interosseous ligament.
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30
Q

Name the 2 ligaments of the foot

A
  1. Lisfranc Ligament - connects the second MT head to the first cuneiform
    2 Transverse metatarsal ligament
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31
Q

Normal ROM of the ankle:
DF:
PF:

A

Dorsiflexion: 20 degrees
Plantarflexion: 50 degrees

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32
Q

Normal ROM of the foot:
Subtalar joint:
Inversion:
Eversion:

Forefoot:
Abduction:
Adduction:

First MTP
Flexion:
Extension:

A

Subtalar joint
Inversion: 5
Eversion: 5

Forefoot:

abd: 10
add: 20

First MTP
Flexion: 45
Extension: 80

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33
Q

Muscles responsible for DF 4

Divide into inverters and everters:

A

Inversion

  • tib ant (deep peroneal L4/L5)
  • extensor hallucis longus (deep peroneal (L4)/L5/S1)

Eversion:

  • Extensor digitorum longus (deep peroneal L5/S1)
  • Peroneus tertius (deep peroneal L5/S1)
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34
Q

Name the Posterior muscles that cause plantar flexion and inversion. 6

A
  1. Tibialis posterior (Tib nerve - L4/5)
  2. Flexor digitorum longus (Tibial nerve - S1/S2)
  3. Flexor hallucis longus (Tibial nerve S2/3)
  4. Plantaris (Tibial nerve S1/2)
  5. Gastrocnemius (Tibial nerve S1/2)
  6. Soleus (Tibial nerve S1/2)
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35
Q

Name the Lateral muscles involved in plantar flexion and eversion.

A

1 Peroneus longus (superficial peroneal nerve L5-S2)

2. Peroneus brevis (superficial peroneal nerve L5-S2)

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36
Q

Name all plantar flexors of the foot. 8

A
  1. Tibialis posterior (Tib nerve - L4/5)
  2. Flexor digitorum longus (Tibial nerve - S1/S2)
  3. Flexor hallucis longus (Tibial nerve S2/3)
  4. Plantaris (Tibial nerve S1/2)
  5. Gastrocnemius (Tibial nerve S1/2)
  6. Soleus (Tibial nerve S1/2)
    1 Peroneus longus (superficial peroneal nerve L5-S2)
  7. Peroneus brevis (superficial peroneal nerve L5-S2)

Basically all of lateral and posterior compartments of the leg minus popliteus

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37
Q

Name the toe flexors (8)

A
  1. Flexor dig longus (Tib S2/3)
  2. Flexor hallucis longus (Tib S2/3)
  3. Flexor dig brevis (medial plantar nerve (tib S2/3))
  4. Flexor Hallucis brevis (medial plantar nerve (tib S2/3))
  5. Quadratus plantae (lateral plantar nerve (tib S2/3))
  6. Interossei (lateral plantar nerve (tib S2/3))
  7. Flexor digiti minimi brevis (lateral plantar nerve (tib S2/3))
  8. Lumbricals
    - 1st lumbrical (medial plantar nerve (tib L4/5)
    - Second, third, and forth lumbricals (lateral plantar nerve (tib S2/3)
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38
Q

Name the 4 toe extensors

A
  1. Extensor digitorum longus (deep peroneal nerve L5/S1)
  2. Extensor hallucis longus (deep peroneal nerve L5/S1)
  3. Extensor digitorum brevis (deep peroneal nerve: S1/S2)
  4. Lumbricals
    - 1st lumbrical (medial plantar nerve (tib L4/5)
    - Second, third, and forth lumbricals (lateral plantar nerve (tib S2/3)
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39
Q

Name the 3 toe abductors

A
  1. abductor hallucis (medial plantar nerve (tibial S2/3)
  2. Abductor digiti minimi (lateral plantar nerve (tib S2/3)
  3. Dorsal Interossei (lateral plantar nerve Tib S2/3)
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40
Q

Name the 2 toe adductors

A
  1. Adductor hallucis (lateral plantar nerve tib S2/3)

2. Plantar Interossei (lateral plantar nerve Tib S2/3)

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41
Q

What is the most common ankle sprain?

Mechanism of injury?

A

lateral ankle sprains _ account for up to 85% of all ankle sprains

inversion on a plantar flexed foot

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42
Q

Name the injured ligaments in lateral ankle sprain (in order)

A
  1. Anterior talofibular ligament (ATFL)
  2. Calcaneofibular ligament (CFL) - stabilizes ankle during inversion
  3. Posterior talofibular ligament (PTFL)
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43
Q

two provocative tests for lateral ankle sprain

A
  1. anterior drawar test - tests integrity of ATFL
    - may show a >5mm displacement
  2. Talar tilt test - tests integrity of CFL and ATFL
    - 5-10 degree difference as compared to the contralateral extremity.
44
Q

describe the grading system for lateral ankle sprains

A

Grade I (Mild) - partial tear of the ATFL; CFL and PTFL are intact. No instability. Mild swelling. Anterior drawar and talar tilt tests are negative

Grade II (Moderate) - complete tear of the ATFL; Partial tear of CFL. diffuse swelling and ecchymosis. Anterior drawer +, Large anterior shift of the ankle or palpable clunk. Talar tilt negative

Grade III (Severe) - Complete tear of ATFL and CFL. both anterior drawer and talar tilt tests are positive.

Dislocation: complete tear of the ATFL, CFL, and PTFL

45
Q

Treatment of lateral ankle sprains based on grade

A

Grades I and II:
Acute - RICE, NSAIDs, analgesics, immobilization
Conservative - rehab. PT ROM, strengthening proprioceptive exercises, taping, and bracing. Modalities: moist heat, warm whirlpool, contrast baths, ultrasound, short wave diathermy

Grade III
Contreversial - conservative vs surgical; 6 month trial of rehab and bracing. Ligament repair, tenodesis of the peroneus brevis. If the patient is a high performance athlete, and conservative treatment fails (ie patient has persistent critical instability) then surgical reconstruction of the torn ligaments may be considered as early as 3 months post-injury.

46
Q

What is the mechanism of injury for peroneus tendon injury

A
  1. Tenosynovitis or rupture - repetitive forceful eversion causing inflammation or degeneration of the tendon or synovium along its course, behind the lateral malleolus to its insertion point
  2. Subluxation or dislocation - a sudden dorsiflexion of the ankle with the foot can cause subluxation or dislocation of the peroneal tendon. This insult is commonly a skiing injury.
47
Q

What pathology?

  1. painful swelling in lateral retromalleolar area along the course of the peroneal tendons
  2. sudden weakness with the inability to actively evert the foot
  3. A popping sensation in the lateral aspect of the ankle
  4. Pain with resisted dorsiflexion and eversion
A

peroneal tendon injury (tenosynovitis or rupture vs subluxation or dislocation)

48
Q

Medial ankle ligaments (Deltoid) is sprained ____ % of the time. Why?

A

5%. Medial collateral ligaments are stronger than lateral ankle ligaments.

49
Q

What makes up the deltoid ligament

A

Anterior tibiotalar ligament
Posterior tibiotalar ligament
Tibionavicular ligament
Tibiocalcaneal ligament

Functions to stabilize the ankle during eversion

50
Q

Mechanism of medial ankle sprain

Grades?

A

foot caught in pronated, everted position with internal rotation of the upper body. (foot strokes ground instead of the ball in soccer)

Grade:

1: stretch
2: stretch/partial tear
3: full tear

51
Q

Name the 2 complications of medial ankle sprain injuries

A

Syndesmosis ankle injuries

Maisonneuve fractures

52
Q 
Tibialis posterior: 
Origin: 
Insertion: 
Function: 
Mechanism of injury?
A

O: interosseus membrane and the posterior surface of the tibia and fibula
I: tuberosity of the navicular, cuboid, and base of the second to fourth metatarsals
F: plantar flexes and inverts the foot: MAINTAINS THE MEDIAL LONGITUDINAL ARCH

MOI: tenosynovitis or tendon rupture. - repetitive forceful inversion causing inflammation or degeneration of the tendon or synovium along its course.

53
Q

tibialis posterior tendon injuries are associated with what bone?

A

5-10% associated with an accessory navicular bone.

54
Q

What pathology?

insidious onset of posteromedial ankle pain increased by activity. Medial hindfoot swelling. Increased pain with pushoff. Weakness with inversion and plantar flexion.

Which test will be positive?

A

tibialis posterior tendon injury

“too many toes sign” with RUPTURE (when viewing the patient’s foot from behind, more toes are visible on the affected side due to collapse of the medial longitudinal arch.

55
Q

Mechanism of injury for achilles tendonitis?

A

repetitive eccentric overload causing inflammation and micro-tears of the tendon.

56
Q

3 mechanisms for achilles tendon rupture

A
  1. Inflammatory: inflammation and degeneration causing a series of microruptures or breakdown in the collagen fibers
  2. Vascular - inadequate vascularization 2-6cm prox to the insertion of the tendon
  3. sudden push off with the foot in extension position (landing from a jumpt)
57
Q

What are the risk factors for achilles tendonitis?

A
  1. Training errors (most common): increase in mileage or intensity, Change in recent footwear
  2. Anatomic causes: hyperpronation, tight hamstrings and heel cords, pes cavus and genu varum

Increased age, leads to inflexibility of the tendon and decreased tensile strength

58
Q

Which test is indicative of an achilles tendon rupture?

A

Thompson test: squeezing the calf should elicit plantar flexion of the foot with an intact achilles tendon. In an achilles tendon rupture, the foot is unable to plantar flex secondary to the tendon separation

59
Q

Why should you not inject CSI into the achilles tendon for achilles tendonitis?

A

The area of hypovascularity 2-5cm proximal to the tendon insertion is where most ruptures occur. Corticosteroids decrease the metabolic rate of the chondrocytes and fibrocytes, weakening the structural integrity of the tendon and articular cartilage.

60
Q

Treatment for achilles rupture (conservative vs surgical)

A

C: brace in PF position for 8-12 weeks while gradually increasing DF until neutral by 12 weeks. (may use heel lifts)

S: cast for 2 weeks post-repair. Then plantar flexiondial lock brace for 4-6 weeks with gradual turn to neutral.

surgical repair is usually reserved for active individuals.

61
Q 
Flexor Hallucis longus injury: 
Origin: 
Insertion: 
Function: 
Mechanism of injury:
A

Origin: distal fibula and interosseus membrane
Insertion: base of the distal phalanx of the great toe
Function: flexes the great toe at all the joints, plantar flexes the ankle.

Mechanism: repetitive push off maneuvers causing inflammmation of the synovium or tendon as it courses in the groove of the sustentaculum tali and behind the medial malleolus to its insertion.

62
Q

Which pathology?

Tenderness along the tendon at the posteromedial aspect of the great toe. Decreased ability to flex the great toe. Increased pain with active plantar flexion and passive dorsiflexion

A

Flexor hallucis longus injury

“dancer’s tendonitis”

63
Q

What is a common issue in women who wear high heel shoes often?

A

Bursitis (retrocalcaneal, bony exostosis, calcaneal apophysis)

64
Q

Retrocalcaneal bursitis anatomy:

A

inflammation of the bursae between the posterior superior portion of the calcaneus and the distal achilles tendon, or a bursa between the skin and the achilles tendon

65
Q

What is a Hanglund deformity?

A

“pump bump” - enlargement of the posterosuperior tuberosity of the calcaneus. Can be cause of retrocalcaneal #1 bursitis.

66
Q

_____ is an an independent area of ossification separated from teh main bone at the cartilaginous plate of the calcaneous. It occurs in younger population expecially female gymnasts from the stresses of gastrocnemius pull.

A

Sever’s disease - an aphophysitis

67
Q

Define apophysis and exostosis

A

A: outgrowth that has never been entirely separated from bone of which it forms a part. such as a process or a tubercle, or a tuberosity.

E formation of new bone extending outward from the surface of bone

68
Q

The ____ refers to the articulation of the tibia and the fibula which is held together by ligaments. Functions to maintain intergrity of the ankle mortise. Resists forces that attempt to separate the tibia and the fibula.

A

Tibiofibular syndesmosis

69
Q

What makes up the tibiofibular syndesmosis?

A

Anterior tibiofibular ligament
Posterior tibiofibular ligament
Interosseus ligament
transverse tibiofibular ligament.

70
Q

What injury might occur after hyperdorsiflexion and forceful eversion of the ankle or secondary to a direct blow to the foot with the ankle held in external rotation

A

high ankle sprain or injury to the tibiofibular syndesmosis.

71
Q

What tests are pertinent for high ankle sprain or injury to the tibiofibular syndesmosis? 2

A
  1. Squeeze test - tenderness on compression of the distal tibia and fibula proximal to the injury
  2. Stress test: With the knee held at 90 degrees and the ankle neutral, the patient experiences pain when the examiner attempts forcefully ot externally rotate the foot.
72
Q

What must you order and what must you be worried about if you have diagnosed a high ankle sprain or injury to the tibiofibular syndesmosis

A

plain films of proximal fibula to rule out the possibility of a Maisonneuve fracture (which is a rupture of the anterior tibiofibular ligament extending through the interosseus membranewhich results in proximal fibula fracture.

73
Q

What is a maisonneuve fracture?

A

a rupture of the anterior tibiofibular ligament extending through the interosseus membranewhich results in proximal fibula fracture.

74
Q

What is injured in a sinus tarsi syndrome?

A

talocalcaneal ligament sprain

75
Q

What is mechanism of injury for sinus tarsi syndrome?

A

talocalcaneal ligament injury

excessive foot pronation causing adduction of the talus. History of arthritis, (RA, gout, or seronegative spondyloarthropathy).
History of prior ankle injury: inversion sprain or fracture of the tibia, calcaneal, or talus.

76
Q

One might see the following injuries to the tibialis anterior tendon

A
  1. tenosynovitis - if inflammation of tendon or synovium as it courses under the superior retinaculum
  2. Tendon rupture - seen in elderly. Eccentric overload.
77
Q

What pathology?

chronic ankle pain with progressive painless foot slap over time. Increased tenderness and weakness with active dorsiflexiona nd passive plantar flexion. Palpable defect may be noted over the anterior aspect of the ankle.

A

tibialis anterior tendon injury

78
Q

Hyperactivity (as with spasticity) of tib ant muscle, would contribute to which deformitY?

A

inversion (varus) and supination positioning in equinovarus deformities.

79
Q

What is a SPLATT procedure?

A

Split Anterior Tibial Tendon Transfer - Tib ant tendon is split, and a portion of the tendon is transferred to the lateral foot. Half remains attached to its site of origin, while the distal end of the lateral half of the tendon is tunneled into the third cuneiform and cuboid bones.

Often done in conjunction with achilles tendon lengthening to decrease plantar flexion.

80
Q

Talar neck fractures:

discuss deep vs shallow lesions

A
  1. shear force on the anterior lateral surface of the talus resulting in a shallow lesion
  2. compressive force on posteromedial surface of the talus results in a deep lesion
81
Q

Describe the Hawkins Classification of Talar neck fractures

A

Type 1: nondisplaced vertical fracture of the talar neck
Type 2: Displaced fracture of the talar neck of the subtalar joint with the ankle joint remaining intact
Type 3: displaced fracture of the talar neck with dislocation of the body of the talus from the subtalar ankle joints.

82
Q

Complication of talar neck fracture 2

A

avascular necrosis - commonly in the talar body. Risk increases as the amount of displacement increases.

fracture fo the talar dome may form a subchondral fragment that can detach and become displaced in the joint space.

83
Q

Plantar fasciitis causes _____ pain. Males or females more predominant?

A

medial plantar heel pain.

Females > males

84
Q

Name the 8 disorders associated with plantar fasciitis

A
  1. pes cavus
  2. pes planus
  3. obesity
  4. tight achilles tendon
  5. bone spur
  6. HLA-B27
  7. Seroneg spondyloarthropathy
  8. heel spur in 50-75% of these patients
85
Q

What pathology?

tenderness over the medial aspect of theheel and the entire plantar fascia. Pain is worse in the morning or at the start of weight bearing activities (standing, walking after prolonged sitting) and decreases during activity.

A

Plantar fasciitis

tight achilles tendon is frequently associated.

86
Q

Treatment of plantar fasciitis? 4

A
  1. modalities/nsaids
  2. orthotics/shoe modifications (heel pads, cushion, lift)
  3. achilles tendon and plantar fascia stretching
  4. nighttime dorsiflexion splints if other conservative measures fail

Inj: DO NOT inject anasthetic/corticosteroid into the subcutaneous tissue or fascial layer. Stay out of the superficial fat pad to avoid fat necrosis.

87
Q

Caused by irritation and degeneration of the distal interdigital nerves in the toes from the plantar nerve with eventual enlargement due to perineural fibrosis. This mass can produce pain in the web spaces between the metatarsal heads

A

Mortons neuroma

88
Q

What site is most commonly affected by mortons neuroma

A

most comonly affects the third intermetatarsal space (between the third and fourth digits) followed by the second intermetatarsal space.

Females > males

89
Q

What pathology?

sharp shooting forefoot pain radiating to the affected digits. Dysesthesias and numbness are common.

Exam?

A

Morton neuroma

apply direct pressure to the interdigit web space with one hand and then applying lateral and medial foot compression to squeeze the metatarsal heads together. Isolated pain on the plantar aspect of the web space is consistent with morton’s neuroma.

90
Q

Treatment of morton neuroma? 3

A
  1. shoe modifications - adequate insole cushioning, wide toe box, low heel height
  2. accommodative padding - metatarsal padding (“neuroma pads”)
  3. CSI injection is dx and tx.
91
Q

What is mechanism of turf toe? What is it actually?

Chronic may progress to ____

A

Turf toe is a metatarsal phalangeal sprain (MTP) seen in athelets after acute injury to the ligaments and capsule of the first MTP joint.

Hallux rigidus.

92
Q

_____ is lateral deviation of the 1st toe.
What angle is significant?
can lead to ______

A

hallux valgus
>15 degrees
bunion - prominence of MT head

93
Q

_____ is seen in DJD of the 1st MTP joint leading to pain and stiffness.

Will have a _____ gait pattern

Can be secondary to which injury?

A

Hallux rigidus

antalgic

MTP sprain

94
Q

Hammertoe presentation:
MTP:
PIP:
DIP

A

abnormality of the lesser toes.
MTP: passively extends when foot is flat
PIP: flexion
DIP: not affected.

95
Q

What causes hammertoe?

A

chronic wear of tight shoes that crowds toes.

96
Q

Claw toe presentation:
MTP:
PIP:
DIP:

A

MTP: extension
PIP: flexion
DIP: flexion

97
Q

What causes claw toe? Including 5 disorders

A

deformity is usually the result of the incompetence of the foot intrinsic musculature, secondary to neurologic disorders affecting the strength of these muscles (ie diabetes, alcoholism, peripheral neuropathies, Charcot-marie-tooth disease and SC tumors)

98
Q

Mallet toe presentation:
MTP:
PIP:
DIP:

A

Normal
Normal
flexed

99
Q

Cause of mallet toe

A

usually result of jamming type injury or wearing tight shoes. can have callus at tip of toe.

100
Q

What is surgical treatment of mallet toe?

A
  1. flexor tenotomy

2. If deformity is fixed, condylectomy is required.

101
Q

What is the actual lisfranc joint?

A

tarsometatarsal joint - injured from a spectrum of midfoot injuries ranging from sprains to fracture/dislocations.

102
Q

Mechanism of lisfranc joint injury

2

A

Low-energy trauma. Caused by direct impact to the joint or by axial loading the midfoot and rotating it.

seen in athletes

High-energy trauma: less common, due to direct, high-impact trauma (ie MVA) with greater damage produced.

103
Q

What is the pathology?

vague foot or ankle pain. pain and swelling localized to the dorsum of the foot. This injury is easily missed and often misdiagnosed as lateral ankle sprain. Pain may be exacerbated by stabilizing the hind foot and rotating the forefoot.

A

lisfranc joint injury

104
Q

Name the 3 common foot fractures

A
  1. Jones fracture - transverse through base of 5th MT
  2. Nutcracker - cuboid
  3. March fx - MT stress fracture

recall stress factors (tibia > fibula> MT)

105
Q

Treatmetn of the following foot fractures:

  1. Jones
  2. Nutcracker
  3. March
A
  1. Jones (transverse through base of 5th MT - NWB x 6 weeks and ORIF if non-union occurs)
  2. ORIF
  3. a. relative rest. b. cast if needed c. 5th MT may require surgery due to increased risk of displacement.
106
Q

_____ is a sprain of the first MTP joint capsule by forced hyperextension. Commonly seen when athletes play on unyielding artificial surfaces with flexible shoes.

A

Turf Toe

Pain is reproduced by passive extension of the first MTP with pain at the joint capsule.

CUCC (26 decks)

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