Ortho Block 4 Flashcards
What are the MC types of arthritis of the foot/ankle
Where does this usually occur?
OA, degenerative
Post-traumatic arthritis
Hallux Rigidus- MTP great toe
Tarsometatarsal- midfoot
Talonavicular- RA
Talocalcaneal
What do PTs w/ arthritis of MTP complain of?
Midfoot OA commonly occurs in ? as ? and can occur after ?
Pain
Lost dorsiflexion
Great toe swelling
Idiopathic in older woman Lisfranc dislocation (tarsometatarsal)
What do PTs complain of who have midfoot OA?
What type of arthritis follows after calcaneous Fxs and what issues do PTs have?
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
Most PTs w/ ankle arthritis have a Hx of ? w/ common Sxs being ?
How do PTs w/ hallux rigidus present?
Trauma
Pain swelling stiff anterior ankle
Loss of MTP motion at start of dorsiflexion
Difficulty pushing off
Newly formed bunion, difficulty wearing shoes
How is hallux rigidus Dx?
Where is pain located in PTs w/ midfoot arthritis?
Pain in middle of flexion-extension arc
Dorsal bump on midfoot w/ TTP
Pain w/ pronation/supination
What test is used for testing tarsometatarsal joints?
What type of x-rays are taken for ankle/foot arthritis and what is usually seen?
Piano key test
Weight bearing x-rays: osteophytes, joint narrowing
Arthritis of first MTP usually shows ? on x-rays
How is arthrits of the foot/ankle Tx non-operatively?
Dorsal osteophytes protruding into metatarsal head
Shoe modification
Orthotics
NSAIDs
Where does RA in the foot usually present?
What Sxs do PTs complain of?
Fore/Mid > Ankle/Hind
Metatarsalgia w/ sublux/dislocation of lesser toe joint
Halux valgus
Posterior tibialis tenosynovitis
What is expected to be seen on x-rays of PTs w/ RA in their foot/ankle?
What labs are drawn on these PTs?
Malalignment
Osteopenia
Erosion
ESR RF
How are PTs w/ RA in their foot/ankle Tx non-operative?
What surgical options are available?
Shoe modification
Injections
Methotrexate
DMARD/TNF-alpha
MTP fusion
Arthrodesis
Tenosynovectomy
What are the two soft tissue masses likely to be seen on the foot/ankle?
How does each one present on PE?
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
How are soft tissue masses on the foot/ankle Tx non-operative?
When do they need to be referred?
Ganglia aspiration
Shoe modification/orthotics
Sxs/Recurrent w/ compliant PT
Define Callus
Define Corn
AKA for hard/soft corn
Hyperkeratotic lesion
Callus on a toe
Hard: heloma durum
Soft: heloma molle
How do calluses present during PE?
How are they managed non-operatively
Painful to direct pressure
Paring w/out drawing blood
Pummus stone
When are calluses referred to Ortho?
Diabetic foot deformities can lead to ? foot
Deformity causing the callus
Charcot foot
How do diabetic foot ulcers present in clinic?
What are the adverse outcomes of this issue?
Red, hot, swollen foot (cellulitis, ulcer)
Charcot
Gangrene
Diabetic foot ulcers from cellulitis is involving ? layers
Where are monofilament tests conducted on the foot?
What gauge of nylon filament is used?
Dermal layer
1st/3rd/5th metatarsal
10g
How can you tell if a foot is diabetic or cellulitis?
What Dx imaging can be done?
1min of elevation and assessment of redness, cellulitis does not lose redness
Tagged WBC NucMed study: cold= Charcot
hot= osteomyelitis
What image is used for assessing diabetic osteomyelitis?
When are diabetic feet referred?
MRI
Unexplained pain
Sudden swelling/pain
Non-healing ulcer
Where do Achilles tendon tears usually occur?
What do PTs complain of when tear occurs?
What adverse event can occur due to this injury
5-7cm proximal to insertion site of calcaneous
Sudden sharp pain
Contracture
What PE test is done when assessing for Achilles tears?
How are these Tx non-operative
When are these PTs referred
Thompson test within 48hrs of injury is most reliable
Pos= no movement
Cam boot w/ heel lift
Rehab w/ immobilization/RICE
ALL are referred
Ankle sprain means ? ligament are sprained?
If it’s a high ankle sprain, which ligament is involved?
ATFL- ant talofibular ligament
CFL- calcaneofibular ligament
AITFL- anterior inferior tibiofibular ligament
If the ATFL and CFL tear during an ankle sprain, what ligament is 3rd in line to tear?
What are the Ottawa ankle rules?
Posterior talofibular ligament
1: inability to bear weight after injury
2: malleolar pressure, posterior side 6cm
3: base of 5th metatarsal
4: navicular pain
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?
NSAIDs + rest
ROM + strength
Proprioception, agility, endurance
Foot sleeps in plantar flexion
What the is the cause of the MC heel pain in adults
Who is it more likely to present in?
Plantar Fasciitis
Obese female
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
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
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
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
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
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
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
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
What are the referral red flags for Tarsal Tunnel syndrome?
Define Bunionette
CRPS
Loss of motor strength
5th MTP joint prominence
PTs w/ bunionette present w/ ? complaint
What is seen on PE
Shoe wearing causes pain
Deformity/corn
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
When are bunionettes referred to Ortho?
What is the MC type of arthritis of the foot?
Pain Sxs
Hallux rigidus
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
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
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
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
How are Hallux valugus Tx surgically?
When are they referred to Ortho?
Osteotomy
Pain Sxs, not cosmetic concerns
What causes ingrown toe nails?
What are the 3 stages
Trimming nails too short w/ added pressure from tight shoes/pressure
Inflammation
Abscess
Granulation
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
Define Interdigital Neuroma
The MC type is AKA ?
Neuroma between metatarsal heads, MC between 3 and 4
Morton’s neuroma
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
How are Interdigital Neuromas managed w/out surgery?
How are they Tx surgically?
Roomy toe box shoe
Injections
Excision/ligament release
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
How are metatarsalgis Tx w/out surgery?
What surgical option is available?
Roomy toe box shoe
Pads/orthotics
Pare callus
Remove condyle
What 2 microbes are MC cause of nail fungus infections
How is the Dx?
Trichophyton rubrum
Trichophyton mentagrophytes
KOH microscopy
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
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
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
Where are sesamoid bones located in the foot?
How many are there?
Flexor Hallucis brevis tendon
2: medial and lateral
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
Define Claw Toe
What can cause this deformity
Fixed MTP extension
PIP flexion
Charcot Marie tooth
RA
Define Hammer toes
Define Mallet toe
Correctable MTP extension, PIP flexion
DIP flexion
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
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
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
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
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
How is Accessory Navicular Tx
Why is Calcaneal apophysitis only a Peds issue?
Relieve pressure
Casting
Excision
Reqs open growth plate
Calcaneal apophysitis is AKA ?
How do these PTs present?
Sever’s Dz
Activity related heel pain
TTP on calcaneous
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
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
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
What is the difference between primary/secondary clubfoot?
When are images taken?
Primary: positional/flexible or idiopathic (middle)
Secondary: neuromuscluar Dz, rigid
Ambulatory children
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
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
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
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
What is the MC foot deformity
How does this deformity develop
Metatarsus adductus
Metatarsal bones deviated inward compared to tarsus bones
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
How are metatarsus adductus PTs Tx?
When are these referred to Ortho?
Flexible- spontaneous self resolution
Rigid- casting/surgery
Lasting >3-6mon
Rigid cases
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
What will be seen on images of Osteochondral lesions of the talus?
How are these injuries quantified?
Mortise w/ medial lesions
CT/MRI
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
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
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
How are tarsal coalitions Tx?
What is the most common reason for pediatric toe walking?
Depends, observation through fusions
Idiopathis w/out neuro issues
Which toe walking Ped PTs are Tx non-operaive w/ observation?
How are they Tx if they’re older?
Occasional/toddler
Serial casting
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
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
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
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
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
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
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
How are calcaneous/talus Fxs Tx?
When are they referred?
Surgery due to articular surface involvement
All, immediately
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
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
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
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
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
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
What is an adverse outcome from a sesamoid Fx?
What is the female athlete triad?
Hallux rigidus
Amenorrhea
Osteopenia
D/o eating habits
Stress Fxs of foot/ankle usually occur ?
What adverse outcome can occur?
MC 2nd MT
5th MT mal/non-union
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
When are stress Fxs Tx w/ surgery?
When are they referred to Ortho?
5th MT
Malunions
Recurrent/non-improving stress Fxs
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
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
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
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
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
What will radiographs show of RA in foot/ankle?
Lateral drifts may be visible at ? locations?
Swelling Osteopenia Subchondral erosion Malalignment
MTP
Talonavicular joint
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
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
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
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
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
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
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
What tissue is primarily involved w/ charcot arthropathy?
This issue leads to what two issues
Synovial
Disrupted joint stability
Severe bone deformities
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
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
