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Ortho Block 4 Flashcards

1
Q

What are the MC types of arthritis of the foot/ankle

Where does this usually occur?

A

OA, degenerative
Post-traumatic arthritis

Hallux Rigidus- MTP great toe
Tarsometatarsal- midfoot
Talonavicular- RA
Talocalcaneal

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2
Q

What do PTs w/ arthritis of MTP complain of?

Midfoot OA commonly occurs in ? as ? and can occur after ?

A

Pain
Lost dorsiflexion
Great toe swelling

Idiopathic in older woman
Lisfranc dislocation (tarsometatarsal)
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3
Q

What do PTs complain of who have midfoot OA?

What type of arthritis follows after calcaneous Fxs and what issues do PTs have?

A

Ache worse w/ walking or long periods of standing
Difficulty w/ pushing off

Subtalar
Pain/difficulty walking on sand/rocky terrain due to loss of in/eversion

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4
Q

Most PTs w/ ankle arthritis have a Hx of ? w/ common Sxs being ?

How do PTs w/ hallux rigidus present?

A

Trauma
Pain swelling stiff anterior ankle

Loss of MTP motion at start of dorsiflexion
Difficulty pushing off
Newly formed bunion, difficulty wearing shoes

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5
Q

How is hallux rigidus Dx?

Where is pain located in PTs w/ midfoot arthritis?

A

Pain in middle of flexion-extension arc

Dorsal bump on midfoot w/ TTP
Pain w/ pronation/supination

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6
Q

What test is used for testing tarsometatarsal joints?

What type of x-rays are taken for ankle/foot arthritis and what is usually seen?

A

Piano key test

Weight bearing x-rays: osteophytes, joint narrowing

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7
Q

Arthritis of first MTP usually shows ? on x-rays

How is arthrits of the foot/ankle Tx non-operatively?

A

Dorsal osteophytes protruding into metatarsal head

Shoe modification
Orthotics
NSAIDs

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8
Q

Where does RA in the foot usually present?

What Sxs do PTs complain of?

A

Fore/Mid > Ankle/Hind

Metatarsalgia w/ sublux/dislocation of lesser toe joint
Halux valgus
Posterior tibialis tenosynovitis

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9
Q

What is expected to be seen on x-rays of PTs w/ RA in their foot/ankle?

What labs are drawn on these PTs?

A

Malalignment
Osteopenia
Erosion

ESR RF

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10
Q

How are PTs w/ RA in their foot/ankle Tx non-operative?

What surgical options are available?

A

Shoe modification
Injections
Methotrexate
DMARD/TNF-alpha

MTP fusion
Arthrodesis
Tenosynovectomy

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11
Q

What are the two soft tissue masses likely to be seen on the foot/ankle?

How does each one present on PE?

A 
MC- ganglia
Plantar fibroma (matosis= plural)

Ganglia- move side to side, usually on top of foot and transilluminate
Fibroma- rubbery, immobile; always on plantar surface

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12
Q

How are soft tissue masses on the foot/ankle Tx non-operative?

When do they need to be referred?

A

Ganglia aspiration
Shoe modification/orthotics

Sxs/Recurrent w/ compliant PT

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13
Q

Define Callus

Define Corn

AKA for hard/soft corn

A

Hyperkeratotic lesion

Callus on a toe

Hard: heloma durum
Soft: heloma molle

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14
Q

How do calluses present during PE?

How are they managed non-operatively

A

Painful to direct pressure

Paring w/out drawing blood
Pummus stone

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15
Q

When are calluses referred to Ortho?

Diabetic foot deformities can lead to ? foot

A

Deformity causing the callus

Charcot foot

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16
Q

How do diabetic foot ulcers present in clinic?

What are the adverse outcomes of this issue?

A

Red, hot, swollen foot (cellulitis, ulcer)

Charcot
Gangrene

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17
Q

Diabetic foot ulcers from cellulitis is involving ? layers

Where are monofilament tests conducted on the foot?

What gauge of nylon filament is used?

A

Dermal layer

1st/3rd/5th metatarsal

10g

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18
Q

How can you tell if a foot is diabetic or cellulitis?

What Dx imaging can be done?

A

1min of elevation and assessment of redness, cellulitis does not lose redness

Tagged WBC NucMed study: cold= Charcot
hot= osteomyelitis

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19
Q

What image is used for assessing diabetic osteomyelitis?

When are diabetic feet referred?

A

MRI

Unexplained pain
Sudden swelling/pain
Non-healing ulcer

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20
Q

Where do Achilles tendon tears usually occur?

What do PTs complain of when tear occurs?

What adverse event can occur due to this injury

A

5-7cm proximal to insertion site of calcaneous

Sudden sharp pain

Contracture

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21
Q

What PE test is done when assessing for Achilles tears?

How are these Tx non-operative

When are these PTs referred

A

Thompson test within 48hrs of injury is most reliable
Pos= no movement

Cam boot w/ heel lift
Rehab w/ immobilization/RICE

ALL are referred

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22
Q

Ankle sprain means ? ligament are sprained?

If it’s a high ankle sprain, which ligament is involved?

A

ATFL- ant talofibular ligament
CFL- calcaneofibular ligament

AITFL- anterior inferior tibiofibular ligament

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23
Q

If the ATFL and CFL tear during an ankle sprain, what ligament is 3rd in line to tear?

What are the Ottawa ankle rules?

A

Posterior talofibular ligament

1: inability to bear weight after injury
2: malleolar pressure, posterior side 6cm
3: base of 5th metatarsal
4: navicular pain

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24
Q

What are the 3 phases of non-operative Tx of ankle sprains

Why does plantar fasciitis hurt so much in the morning/with first step?

A

NSAIDs + rest
ROM + strength
Proprioception, agility, endurance

Foot sleeps in plantar flexion

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25
What the is the cause of the MC heel pain in adults Who is it more likely to present in?
Plantar Fasciitis Obese female
26
What will be seen on PE of plantar fasciitis What is a possible finding on imaging?
TTP plantar calcaneous 1-2cm distal on plantar calcaneous Inc pain w/ toe extension Plantar bone spur
27
What are the 4 location causes of posterior heel pain? What are the clinical Sxs of each
Achilles insertion Retrocalcaneal bursa Achilles tendon Pre-Achilles burs Bursitis= pump bump Haglund= bone Paine w/ shoes
28
What may be seen on PE of posterior heel pain? How are these managed non-operative and what Tx is avoided?
Swelling/TTP on posterior heel Dec pressure Stretching NO steroids
29
Where does the posterior tendon insert in the foot? Who does it usually present in? What is an adverse development of this Dz?
Navicular bone forming arch of foot Overweight female >55y/o Valgus ankle
30
What will be seen on PE of posterior tibial tendon dysfunction What would be seen on lateral imaging in advanced cases?
Medial ankle pain Too many toe sign Unable to perform single leg calf raise Pes planus- weight bearing
31
How are posterior tibial tendon dysfunctions managed non-operative? What surgical options are available? When do these PTs need to be referred?
4wk short leg cast NO steroids Flexible: tendon transfer + osteotomy Rigid: arthrodesis Medial/navicular ankle pain
32
# Define Tarsal Tunnel Syndrome How do PTs present complaining of?
Compression of tibial nerve on medial ankle Paresthesia Dysesthesias TTP on posterior medial ankle Tinels test
33
What studies can be done for Tarsal Tunne Syndrome to aid w/ Dx? How is this managed w/out surgery? What type of surgery option is available?
EMG/NCV Dec stretch w/ shoe/orthotic modifications Surgical release
34
What are the referral red flags for Tarsal Tunnel syndrome? Define Bunionette
CRPS Loss of motor strength 5th MTP joint prominence
35
PTs w/ bunionette present w/ ? complaint What is seen on PE
Shoe wearing causes pain Deformity/corn
36
What would be seen on x-rays of bunionettes How are these managed w/out surgery? How are they managed surgically?
Medial deviation proximal phalynx Lateral deviation of metatarsal Shoe modification Osteotomy
37
When are bunionettes referred to Ortho? What is the MC type of arthritis of the foot?
Pain Sxs Hallux rigidus
38
What type of pain doe PTs w/ Hallux Rigidus complain of? What will be seen on PE?
Toe off pain Dorsal osteophytes Stiff/dec extension Mid range pain= inc severity
39
What would be seen on x-rays of Hallux Rigidus How can they be Tx w/out surgery? How are they surgically corrected
Dorsal/lateral osteophytes Stiff sole shoe Roomy toe box Chellectomy- removal of bone spurs Arthrodesis- won't be able to flex foot
40
What is the MC malady of the great toe? What causes this issue?
Hallux Valgus Hallux Rigidus- #2 Toe moves laterally Metarsal moves medially causing prominence
41
How is the angle of Hallux Valgus measured? How are these managed w/out surgery
Intermetatarsal Angle, norm <10* Metatarsal/Phalynx joint angle= hallux valgus angle, norm <50* Roomy toe box shoe
42
How are Hallux valugus Tx surgically? When are they referred to Ortho?
Osteotomy Pain Sxs, not cosmetic concerns
43
What causes ingrown toe nails? What are the 3 stages
Trimming nails too short w/ added pressure from tight shoes/pressure Inflammation Abscess Granulation
44
How are ingrown toe nails Tx w/out surgery? What is the intermediate option?
Warm soaks Proper trimming Clean socks/roomy shoes PO ABC Nail plate excision
45
# Define Interdigital Neuroma The MC type is AKA ?
Neuroma between metatarsal heads, MC between 3 and 4 Morton's neuroma
46
How do PTs w/ interdigital neuromas present complaining of? What will be seen on PE?
Walking on marble/stones Plantar pain Metatarsal head compression test
47
How are Interdigital Neuromas managed w/out surgery? How are they Tx surgically?
Roomy toe box shoe Injections Excision/ligament release
48
# Define Metatarsalgia What do these PTs present complaining of? What will be seen on PE? What type of images are needed?
Aliga at lesser MT heads, 2-5 Walking on pebbles (underneath heads, not in between them) Platar forefoot Callus Weight bearing lateral
49
How are metatarsalgis Tx w/out surgery? What surgical option is available?
Roomy toe box shoe Pads/orthotics Pare callus Remove condyle
50
What 2 microbes are MC cause of nail fungus infections How is the Dx?
Trichophyton rubrum Trichophyton mentagrophytes KOH microscopy
51
What is an adverse outcome of using anti-fungals for nail infections? When are these PTs referred to Ortho?
Inc liver enzymes Elderly Liver unable to tolerate anti-fungals
52
What causes Platar Warts When they grow together/on top of each other, what are they called? Where will they be seen on the foot during PE?
Human Papilloma virus, patterns cease at edge Mosaic warts Non-weight bearing surfaces (not on metatarsal head) Pain w/ pinching
53
How are plantar warts managed? What are the adverse events of Tx?
``` Par/Keratolytic w/ occlusion Electrocautery* Cryotherapy Laser ablation* Curretage ``` Painful scar Aerosolized wart inhalation by provider
54
Where are sesamoid bones located in the foot? How many are there?
Flexor Hallucis brevis tendon 2: medial and lateral
55
What Sxs are seen during PE of sesamoiditis? How are these Tx non-surgically? How are they Tx surgically
Pain w/ forced extension 1st MT head Pain w/ extension No high heel shoes Excision
56
# Define Claw Toe What can cause this deformity
Fixed MTP extension PIP flexion Charcot Marie tooth RA
57
# Define Hammer toes Define Mallet toe
Correctable MTP extension, PIP flexion DIP flexion
58
How are foot/toe deformities Tx w/out surgery? What does surgical Tx offer? When are these cases referred to Ortho?
Roomy toe box shoe Rehab- strength and flexibility Proper alignment Claw toe + high arch= neuro cause/Charcot Marie
59
# Define Turf Toe How are these injuries graded? What is the adverse outcome of this injury?
1st MTP sprain after hyper flexion 1: stretch, continue play 2: partial plantar tear 3: complete, don't play Hallux rigidus
60
Why are images taken of Turf Toe injuries? How are these Tx w/out surgery
R/o avulsion Fxs Grade 1/2: stiff sole shoe Grade 3: NWB x 2wks, no playing x 6wks
61
What are the 3 types of foot/ankle pain?
Os Trigonum- ossicle on posterior talus causing impingement w/ plantar flexion; Tx RICE/excision Osteonecrosis- navicular bone, AKA Kohler Dz, seen in boys 4-8y/o; Tx w/ casting/activity modification Freiberg infarction- osteonecrosis of MT head #2; Tx w/ reduced activity, padding or casting to dec pressure while healing
62
# Define Accessory Navicular How do they present and what is seen on PE? What image is used for Dx
Medial navicular at posterior tibialis tendon insertion TTP on medial arch TTP on ossicle Resisted inversion DP radiograph
63
How is Accessory Navicular Tx Why is Calcaneal apophysitis only a Peds issue?
Relieve pressure Casting Excision Reqs open growth plate
64
Calcaneal apophysitis is AKA ? How do these PTs present?
Sever's Dz Activity related heel pain TTP on calcaneous
65
What would be seen on x-rays of calcaneal apophysitis that is actually normal? How are these cases Tx?
Sclerosis on calcaneous Rarely casting Activity modification Heel lifts
66
# Define Cavus foot deformity Define Cavovarus Define Equinocavovarus What type of d/o is this?
High arch Hind foot varus Hind foot equinus, plantar flexion Neuromuscular- Charcot Marie
67
What type of imaging is used for assessing Cavus foot deformities? Club foot is AKA ? What does the CAVE acronym stand for in this d/o?
Meary angle on x-rays Talipes equinovarus Cavus, midfoot Adduction, forefoot Varus heel Equinus ankle
68
What is the difference between primary/secondary clubfoot? When are images taken?
Primary: positional/flexible or idiopathic (middle) Secondary: neuromuscluar Dz, rigid Ambulatory children
69
How are PTs w/ clubfoot managed/Tx? Most of these are Tx operative, but what is the adverse outcome?
Ponseti method of serial casting and Achilles release Casting can't help w/ Equinus/Plantar flexion, usually causes Achilles contraction Moderate recurrence rates
70
Flat foot is AKA ? When does the arch of the foot begin to show and when is it fully developed?
Pes planus Starts @ 4yrs Done by 10yrs
71
What is seen on PE of Pts w/ flatfoot? How can their ankle flexibility be assessed?
Medial malleolus prominence Extend great to and have PT stand on toes
72
How are Flatfoot deformities Tx w/out surgery When are flatfoot PTs referred to ortho?
Flexible cases: flexible shoes and reassurance Rigid: surgery, calcaneal osteotomy Rigid flatfoot PTs
73
What is the MC foot deformity How does this deformity develop
Metatarsus adductus Metatarsal bones deviated inward compared to tarsus bones
74
How is the severity of metatarsus adductus graded? What is the imaging used to assess these cases?
Line through heel, assess where it bisects w/ toes Mild: 3rd toe Moderate: 4th toe Severe: 5th/pinky toe Photocopy tracking
75
How are metatarsus adductus PTs Tx? When are these referred to Ortho?
Flexible- spontaneous self resolution Rigid- casting/surgery Lasting >3-6mon Rigid cases
76
What type of injury force causes osteochondral lesions of the talus? What are the Sxs of this condition? What will be seen on PE?
Bone + cartilage due to trauma/idiopathic compression causing medial bone and lateral ligament injuries Hx of catching/popping Limited ROM Anterior joint line pain Laxity- anterior drawer to test ATFL
77
What will be seen on images of Osteochondral lesions of the talus? How are these injuries quantified?
Mortise w/ medial lesions CT/MRI
78
When are osteochondral lesions of the talus Tx w/out surgery? Which of these cases are referred to Ortho?
Skeletal immature= immobilization Mature= surgery All
79
# Define a Tarsal Coalition How/why do these PTs present to clinic?
Tarsal are connected Talocalcaneal or Calcaneonavicular coalitions may be MC Pain w/ activity Frequent sprains
80
What would be seen on PE of tarsal coalitions? What is the name of the special view used for assessing this condition?
Rigid flatfoot Dec in/eversion Harris heel view- 45* posterior/inferior view of heel
81
How are tarsal coalitions Tx? What is the most common reason for pediatric toe walking?
Depends, observation through fusions Idiopathis w/out neuro issues
82
Which toe walking Ped PTs are Tx non-operaive w/ observation? How are they Tx if they're older?
Occasional/toddler Serial casting
83
When are Peds w/ toe walking referred to Ortho? Where do Fx/dislocations of the midfoot usually occur?
Abnormal PE Tight Achilles Unilateral toe walking Mental/developmental concerns TMT joint- MC 2nd metatarsal/cuneiforms: Lisfranc dislocation
84
What needs to be done on PE when assessing Fx/dislocation of the midfoot? What kind of x-rays are needed? What may be seen on x-rays?
ROM between talus/calcaneous (hind foot) and midfoot Bilateral weight bearing, CT or MRI Widening between middle cuneiform and 2nd metatarsal/avulsion Fx
85
How are Fx/dislocations of the midfoot Tx w/out surgery When is surgery needed for Tx? How many malleoli are in the ankle and how are they named by Fxs?
6-8wks NWB then, Rigid shoe x 3mon Displaced fx 3: lateral, medial, posterior Bimalleolar: lateral, medial Trimaleolar: all 3
86
What are the adverse outcomes of a foot/ankle Fx What needs to be assessed on PE?
Talar OCD NV exam Palpate- knee (Maisonneuve) Distal of both malleoli
87
# Define a Maisonneuve Fx How are foot/ankle Fxs Tx non-surgically?
Ankle trauma travels up leg through osseous membranes, exits through lateral fibula Distal tib/fib avulsion= WBAT x 6wks in CAM boot Unstable Fx= reduction, surgery
88
When are foot/ankle Fxs referred? What limb threatening issue can develop from calcaneous/talus Fxs? What other issue needs to be r/o w/ these Fxs?
Open/unstable Fxs Plantar compartment syndrome Spine injury if PT fell from height onto feet
89
What type of x-rays are needed when assessing calcaneous/talus Fxs? What image is needed if this is a suspected intra-articular Fx?
Harris heel view CT
90
How are calcaneous/talus Fxs Tx? When are they referred?
Surgery due to articular surface involvement All, immediately
91
Most metatarsal Fxs are stable with ? exception? Which of these Fxs are at risk for mal/non union and compartment syndrome?
Proximal to 5th MT zone 2 Zone 2 or 3 5th MT Fxs
92
How are metatarsal Fx 1-4 Tx non-surgically? How are 5th MT Fx managed? Which ones require surgical Tx?
WBAT x 6wks Zone 1= WBAT x 6wks Above zone 2= non operatiely w/ NWB and cast x 6wks 5th MT zone 3 >4mm displacement >10* angulation
93
What is the MC toe to be Fx? How are these Fxs managed w/out surgery?
Small toe at proximal phalanx Buddy taping after r/o rotation
94
What type of toe Fx needs surgical correction? What is a normal variant of the sesamoid bones?
Great toe MTP intra-articular Bipartite Fx pattern MC in medial
95
What type of mechanism of injury causes a Fx sesamoid bone? What will be seen on PE?
Hyperextension of great toe Plantar TTP Dec ROM
96
What imaging modality is used to differentiate if a sesamoid is Fx or bipartite? How are these managed w/out surgery? When do they need surgical Tx?
Bone scan WBAT x 4wks MT pad Plantar plate rupture/Turf toe
97
What is an adverse outcome from a sesamoid Fx? What is the female athlete triad?
Hallux rigidus Amenorrhea Osteopenia D/o eating habits
98
Stress Fxs of foot/ankle usually occur ? What adverse outcome can occur?
MC 2nd MT 5th MT mal/non-union
99
What are the time frames for ordering certain imaging modalities for stress Fxs? How are most stress Fxs managed?
Plain: 3-4wks Bone scan: 24-48hrs MRI: 72hrs WBAT CAM boot x 4wks Calcaneous/fibula: WBAT x 2-4wks Navicular/5th MT: NWB x 4wks
100
When are stress Fxs Tx w/ surgery? When are they referred to Ortho?
5th MT Malunions Recurrent/non-improving stress Fxs
101
What imaging is ordered to assess OA of the midfoot when bony anatomy is difficult to see? What imaging is ordered if the source of a PTs foot pain is difficult to identify?
CT SPECT CT
102
What type of shoe may help relieve Sxs of pain w/ hallux rigidus? What surgical procedure is performed if non-surgical Tx fails?
Stiff sole shoe w/ rocker bottom Debridment of 1st MTP w/ cheilectomy/arthrodesis
103
How is midfoot arthritis Tx non-surgically? How are Sxs of talonavicular/subtalar arthritis improved? How can talonavicular/subtalar arthritis be Tx definitively?
Orthotic/steel shank in sole of show w/ CCS injections Medial longitudinal arch support More rigid UCBL orthoses Arthrodesis w/ retained ankle motion
104
How are PTs older than 60y/o with mild/moderate deformity from foot/ankle arthritis Tx? PTs w/ chronic synovitis from RA leads to ? structural deformities?
Replacement, better results than fusions Hallux valgus Claw toe w/ sublux/dislocated MTP End stage arthritis of ankle/subtalar joint
105
What may be the presenting Sx of PTs w/ RA What presenting trifecta should lead to suspicion of RA?
MTP synovitis w/ focal pain/swelling over MTP joints Bilateral Sxs, Multiple Joints and Nodules
106
What will radiographs show of RA in foot/ankle? Lateral drifts may be visible at ? locations?
Swelling Osteopenia Subchondral erosion Malalignment MTP Talonavicular joint
107
When are CCS injections beneficial for RA of the foot/ankle? What is the most reliable surgical Tx for forefoot deformities? What procedure needs to be avoided?
Inflamed joints Severe tenosynovitis Fusion of 1st MTP w/ metatarsal heads Implant arthroplasty of great toe
108
Since tensosynovectomy only provides temporary relief for RA of ankle/foot, what procedure do most PTs get? What procedure may be done for young PTs w/ RA but has shown to produce worse results than BTK amputations?
Arthrodesis of talocalcaneal, talonavicular and calcaneocuboid joints. Still retains dorsi/plantar flexion Tibiotalocalcaneal fusion
109
Where do ganglion tumors arise from on the feet? Ganglia of the foot usually arise from ? while ganglion cysts arise from ?
Joint capsule or tendon sheath Top/side of foot Subtalar/ankle joint
110
Plantar fibromas is a benign thickening of ? which can turn into a condition similar to ? How do ganglion/fibroma Tx differ?
Plantar fascia Plantar fibromatosis, similar to Dupuytren Dz Ganglion: aspiration w/ 18g Fibroma: shoe modification, orthotics
111
A persistent callus on the sole of the forefoot is AKA ? What 3 toe deformities can lead to corn development?
Intractable plantar keratosis Hammer/claw toe Bunionette
112
What is the difference in growth between a heloma durum and molle? How do you tell a wart from a callus?
Molle- Between toes in web space and over bony prominence Durum: exposed bony prominence only Wart- tender w/ side to side pinching Callus- tender w/ direct pressure
113
What diabetic issue predisposes them to ulceration? Motor neuropaty leads to weakness of the intrinsic muscles which can cause what five issues of the foot
Autonamic dysfunction- dry, scaly, cracking skin ``` Claw toe Subluxation/dislocation Abnormal plantar positioning Inc pressure on sole of foot Skin break down ```
114
What tissue is primarily involved w/ charcot arthropathy? This issue leads to what two issues
Synovial Disrupted joint stability Severe bone deformities
115
What Dx can be suspected if PT w/ diabetic ulcer can be probed down to the bone? What is the goal of Tx for diabetic foot problems?
Osteomyelitis PT education and prevention Once neuropathy starts, irreversible
116
What is the first finding/Sx that a diabetic foot ulcer may be developing What is the difference in resting position of a leg w/ an intact and torn Heel Chord?
Callus Intact: plantar flexion when hanging/PT is prone Torn: foot hangs at 90* to tibia

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