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IPAP > Ortho Block 4: Detailed > Flashcards

Ortho Block 4: Detailed Flashcards

1
Q

What causes stress Fxs

Stress Fxs can also be AKA ?

A

Repetitive overloading causing bone failure when fatigue out lass repair processes

Insufficiency Fxs

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2
Q

Why are younger females at higher risk of stress Fxs

Why are older women at higher risk?

A

Female athlete triad: amenorrhea, osteopenia, eating d/os

Osteoporosis

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3
Q

What is the MC site of stress Fxs

Where can they also develop through out the foot and ankle

A

Metatarsals, especially #2

Navicular
Calcaneous
Medial malleolus
Fibula

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4
Q

How do PTs w/ stress Fxs present

What is the most reliable physical sign for these on PE?

A

Inc pain w/ weight bearing
Dec pain w/ rest
Metatarsal Fx= dorsal swelling
Fibula Fx= swollen lateral ankle

Pain/tenderness and swelling localized over area

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5
Q

How long does it take stress Fxs to show on imaging?

What two types of stress Fxs are at risk for malunion/non-union healing if proper rest is not observed?

A

3-4wks on x-ray
5 days on bone scan
MRI can confirm Dx, not routinely used

Jones Fx of 5th metatarsal
Navicular stress Fxs

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6
Q

How are stress Fxs in different locations Tx

How are 5th metatarsal stress Fxs better Tx in an athletic PT?

A

Metatarsal: stiff sole shoe/short leg brace
Calcaneal/fibular: 2-4wks imobilization in short leg cast
Navicular/5th metatarsal: casted, NWB

Internal fixation

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7
Q

Heel varus= ? Fx
Heel valgus= ? Fx

Which stress Fxs are referred w/ red flags?

A

Varus: 5th MT Fx
Valgus: fibula Fx

Navicular, 5th MT, all fibular
Failure to heal in 6wks/Recurrent Fxs= metabolic work up

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8
Q

1st MTP has ? sesamoids and which is more prone to Fx

The plantar aspect of each is surrounded by ? tendon

What does the dorsal aspect of the sesamoids articulate w/?

A

2: lateral, medial*

Flexor hallucis brevis
Plantar plate

Metatarsal head

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9
Q

What are 3 MOIs that can cause a sesamoid Fx

Dancing or running will cause ? types of Fxs

A

MC: direct trauma
Avulsion from MTP hyperdorsiflexion
Stress

Stress or Avulsion

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10
Q

What is the MC site for accessory sesamoids to be found

What type of sesamoid is a normal variant?

What do PTs complain of during PE when sesamoid is Fx?

A

Second MT head on tibial side

Bipartite

Point of pain will move w/ toe flexion/extension
Inc pain w/ dorsiflexion of 1st MTP

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11
Q

How are sesamoids best evaluated w/ imaging?

What imaging is used to differentiate between acute or stress Fxs of bipartite and sesamoids?

What imaging is used to differentiate between a Fx of the bipartite sesamoid or osteonecrosis?

A

Lateral: w/ internal oblique view
AP/Lat/Axial views

Tc-99m bone scan

MRI- marrow edema if Fx is present

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12
Q

How are sesamoid Fxs Tx w/out surgery

When do these types of Fxs have to be Tx w/ surgery

What is the adverse outcome of this injury

A

Short leg brace or stiff sole shoe w/ rocker bottom
When Sxs improve- felt pad x 6mon

Fx w/ plantar plate rupture

6-12mon healing time= limited dorsiflexion of 1st MTP

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13
Q

Phalangeal Fx usually involves ? part and is due to ?

Which toe is MC affected

What is the MC unlikely adverse outcome of this injury

A

Proximal phalynx
Direct trauma

5th toe

Permanent deformity

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14
Q

How are phalangeal Fxs Tx w/out surgery

When do these Fxs need to be reduced

When do they need to be referred?

A

Buddy taped to medial toe w/ gauze pad in between to prevent maceration

Angulated
Articular surface involvement
Interphalangeal joint involvement of great toe

Open/displaced intra-articular Fx

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15
Q

What type of metatarsal Fxs are unique and need extensive immobilization

How long can it take for a stress Fx on a metatarsal to show up?

A

Zone 2 proximal diaphysis of 5th metatarsal (Jones Fx)
Zone 3 of 5th MT, usually stress Fx

2-3wks

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16
Q

Define Zone 1-3 on the 5th MT

How are these Tx w/out surgery

How often are images needed

A

1: articular surface
2: articulation of proximal 4th and 5th MTs
3: extends 1.5cm distal to zone 2

Short leg cast/brace

Repeated @ 1wk and 6wks

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17
Q

A Fx of the 1st MT if often the result of ? injury and requires ? for Tx

What types of Fxs require surgical correction to protect weight bearing function of the foot?

Fx to Zone 3 can resemble ? Fxs

A

High impact injury
Surgery

Multiple Fxs w/ more than 4mm displacement
Apical angulation >10* on lateral view

Stress Fx exacerbated w/ inversion injury

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18
Q

What type of Fx to the 5th MT is more difficult to Tx

What are the 2 bones of the hind foot usually Fx during MVAs or falls

A

Acute Fx to Zone 2- NWB x 6-8wks
Athletes= internal fixation

Calcaneous
Talus

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19
Q

Since compartment syndrome is difficult to identify due to calcaneous/talus Fxs, what finding is indicative

Calcaneous Fxs need to have ? other injury r/o

A

Swelling in area of arch

Spinal Fx on ipsilateral side of injury

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20
Q

What x-ray views are needed to assess calcaneous Fxs

Coronal CT images are needed if suspected nerve entrapment is present

A

AP Lateral Mortise Harris

Evaluate subtalar/calcaneocuboid joints

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21
Q

Fx to ? bone in the ankle frequently leads to osteonecrosis

What are the first two things done during Tx of these injuries

A

Talus

Elevation above heart
Ice q20min

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22
Q

Ankle Fxs include injuries to ? bones

Unstable ankle Fxs involve ?

A

Lateral/Medial/Posterior malleolus
Collateral ligaments
Talar dome

Both sides of joint
Bimalleolar: lat/medial malleolus or distal fibula w/ disrupted deltoid ligament
Trimalleola

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23
Q

Posterior dislocation of the ankle may be present w/ ? Fx

What type of PE finding is assumed to be an unstable bimalleolar injury

A

Trimalleolar

Fx of distal fibular w/ TTP over medial deltoid ligament

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24
Q

Define a Maisonneuve Fx

What type of x-ray view allows for clear evaluation of the tibia, fibula and talus

A

Fx of proximal fibula from unstable external rotation injury including Fx of fibula, tear of medial deltoid and disrupted tibiofibular ligaments

Mortise view

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25
If ankle injury doesn't show Fx on initial x-rays, how long until repeat x-rays are taken? What type of Fx may be present in the ankle after a rotational injury?
10-14 days Osteochondral Fx
26
How are stable, unstable, unstable/not displaced Fx of the ankle Tx If an osteochondral fragment is present in the joint space, successful pinning and fixation is only successful in ? PTs?
Stable: WBAT w/ cast x 4wks Unstable, not displaced: NWB w/ cast and immobilization Unstable, displaced: reduction needed Young
27
When is rehab indicated after an ankle Fx Define Lisfranc Fx-dislocation
Elder PT Full ROM/balance not returned by 3mon Fx-dislocaiton to the midfoot at the tarsometatarsal joints
28
How can Lisfranc Fx/Dislocations occur in athletes What does this 'critical' injury involve Where will PTs point their pain to be during PE
Tripping 2nd MT, joint wedges into slot in cuneiforms and is key to stabilizing other midfoot joints Dorsum of midfoot
29
How can you tell a Lisfranc injury from an ankle sprain What x-ray findings are indicative of a 'normal' foot and no injury
Stabilize calcaneous, rotate/abduct forefoot w/ other +pain= Lisfranc Medial aspect of cuneiform lines up w/ medial 2nd MT Medial aspect of 4th MT lines up w/ medial cuboid
30
What does the Lisfranc ligament join and what does it provide? What is the next step if injury suggests what x-rays don't show?
Base of 2nd MT and medial cuneiform Stability to tarsometatarsal joints Sedation w/ stress radiographs of midfoot
31
What types of deviation is seen during a Lisfranc injury How are these Tx w/out surgery
Fragment at base of 2nd MT Lateral deviation of 2nd and 3rd MT Medial deviation of 1st MT 8wks NWB, 3mon of rigid arch support Any displacement= reduction and fixation
32
What can be added to a bandage surrounding a Lisfranc injury to reduce edema What two Dzs are r/o when evaluating idiopathic toe walking What PT population is toe walking common in?
Zinc oxide cream Cerebral palsy Muscular dystrophy Speech/language delays Autism
33
When quantifying the degree of dorsiflexion of a toe walker, what PE finding is indicative of an Achillies contracture How are these cases Tx when Pt is a toddler
<10* passive dorsiflexion Self resolve in 3-6mon Autistic- PT, OT
34
When is serial casting for toe walking needed What are the MC causes of unilateral toe walking?
Co-existing Achilles contractures Limb length discrepancy Cerebral palsy Tethering of spinal cord
35
# Define Tarsal Coalition How is this condition linked w/ FamHx Which types begins to present w/ Sxs earlier
Abnormal connection between two tarsal bones, MC calcaneous and navicular or talus and calcaneous ASx but no hindfoot motion Calcaneonavicular @ 9-13y/o w/ lateral pain Talocalcaneal @ 13-16y/o deep in hind foot
36
What is seen in PTs w/ tarsal coalition on PE What x-ray view is best for talocalcaneal bars
Rigid flat foot- hind foot valgus, fore foot abduction No longitudinal arch Restricted hindfoot motion from spastic peronial muscles Harris heel view
37
What is the preferred Tx of tarsal coalitions after non-surgical efforts fail What procedure is reserved for those who do not respond to resections or who are not candidates due to large coalitions or arthritic changes being present?
Resection of coalition w/ interposition of fat/muscle Hind foot arthrodesis
38
Osteochondral lesions of the hyaline cartilage and subchondral bone can occur in what two ways? How does this present?
Trauma: osteochondral Fx Idipathic: subchondral avascularity Pain, swelling/effusions, giving away Hx of repeat/chronic sprains Limited/painful A/PROM
39
What type of x-ray view is needed for viewing osteochondral lesions of the talus? What will be seen? What imaging is used for Dz staging?
Mortise views Articular surface defect w/ halo of lucent bone on weight bearing surface CT for medial lesion staging MRI for cartilage/vascular assessment
40
How are osteochondral lesions Tx Define Metatarsus Adductus and what causes it
If skeletal immature: time/immobilization Skeletal mature: surgery Medial deviation/adduction of forefoot MC form intrauterine positioning issue
41
Metatarsus adductus usually presents w/ ? other positional deformities What toe malformity may be observed but usually self resolves?
Congenital muscular torticollis Medial tibial torsion Hip dysplasia- rare Atavistic/wandering adduction of great toe
42
What images are used to track metatarsus adductus Since most cases self resolve, what parent education piece needs to be followed? When do these cases need to be referred?
Foot photocopies Hip US Don't place baby prone w/ feet turned in Residual after 3-6mon old Rigid adductus
43
An abnormally low or absent arch of the foot that in most cases is a normal variant commonly seen in infants and kids What is the MC Dx of this variant
Flat foot Flexible flatfoot
44
What are the etiologies of flat foot? When is idiopathic rigid flatfoot commonly seen?
Congenital: tarsal coaltion, vertical talus Neuromuscular: cerebral palsy, hypotonia Inflammatory: juvenile idiopathic arthritis Obesity
45
What PE test is used to assess flatfoot? How is hindfoot flexibility assessed in these PTs?
Jack test: great toe extension test, re-creates arch during weight bearing in a flexible flatfoot Tiptoe standing
46
What parental education needs to happen for kids w/ flat feet? What is the exception to Peds needing surgical Tx for their flexible flatfoot?
Orthotics have no bearing on self resolving cases People w/ high arcs are usually in pain while flat feet are ASx Sxs persist despite stretching, orthosis, and shoe modificaitons= Osteotomy to lengthen lateral foot columns
47
# Define Talipes Equinovarus What is the acronym for this conditions?
Club foot Cavus, midfoot (high arch) Adduction, forefoot ( Varus, heel (adduction) Equinus, ankle (plantar flexion)
48
How are positional club foots differentiated from inherent flexibility of a deformity What congenital d/os are associated with club foot?
Spontaneous/rapid resolution Absence of calf atrophy/foot size difference Myelomeningocele Arthrogryposis
49
What PE finding is common in congenital club foot and may even remain after Tx? What social concern needs to be present when Tx this condition abroad? What is the TxOC in the US?
Calf atrophy Many of these PTs are ostracized due to belief condition is cursed Ponseti method: all components of CAVE are Tx except hind foot equinus
50
What causes a Cavus Foot deformity Define Cavovarus Define Equinocavovarus
Abnormally high arch from equinus (plantar flexion) Forefoot equinus Hind foot equinus
51
Unilateral cavus foot is usually due to ? while bilateral cavus feet are due to ? Define the Meary angle
Tethered spinal cord CMTooth Dz Cavus foot deformity causing 1st MTP is plantar flexed compared to talus causing increased angle
52
What causes Calcaneal Apophysitis What ages does this normally self resolve?
Activity related pain in posterior heel from stress/microtrauma 9y/o in girls 11y/o in boys
53
What is a common variant seen on x-rays of calcaneal apophysitis This issue can AKA ?
Calcaneous sclerosis Sever's Dz
54
# Define Accessory Navicular What may be seen on PE of this issue
Secondary ossification center develops on medial portion of tarsal naviular bone at attachment site of tibialis posterior tendon TTP medial aspect of navicular Pain w/ inversion resistance Flexible pes planus
55
What is the TxOC for PTs w/ persistent accessory navicular Sxs Define Os Trigonum What causes pain w/ this d/o
Excision of navicular portion Secondary ossification center on posterior talus that is Sx on soccer/ballet Impingement between talus and tibia w/ plantar flexion
56
Osteochondritis dissecans of the talus may result in ? 3 issues What is a common cause of rigid flat feet in kids?
Pain w/ activity Locking of joint Swelling Tarsal coalition
57
Osteonecrosis of navicular bone is AKA ? How do these PTs present How is it best Tx
Kohler Dz Male 4-8y/o w/ limp and out-toeing of foot during walk Short leg walking cast x 4-8wks
58
# Define a Freiberg infarction How does it present?
Osteonecrosis of head of 2nd MT Adolescents after trauma TTP on MT head w/ movement
59
How are ASx Hallux Valgus cases Tx What is the adverse outcome when this presents in Peds? Define Turf Toe and what causes it
Night brace Post-operative recurrence rate is higher Sprain of 1st MTP from hyperextension/forced ROM
60
What are two unique facts about Turf Toe How are these injuries graded
Significant morbidity association Account for more missed game time than ankle sprains 1: stretch injury of the capusle 2: partial tear of plantar ligament 3: complete tear of MTEP ligament; no playing, can't walk normally
61
What are two adverse outcome from a Turf Toe injury How are these injuries Tx
Hallux Rigidus Instability 1, 2: stiff/rocker sole shoe 3: protected weight bearing/immobilization x 2wks, 6wk rest period from sports
62
What is the MC cause of lesser toe deformities
Improperly fitting shoes Intrinsic (foot) muscle imbalance Extrinsic (leg) muscle imbalance
63
# Define Claw Toe This d/o affects ? toes This can be due to ? issues
Fixed extension of MTP, flexion of PIP, +/- DIP contraction All lesser toes Charcto Tooth Dz, RA
64
What PT population frequently develops claw toes? Define Hammer Toe What is the difference in appearance w/ weight/non-weight bearing
DM w/ peripheral neuropathy Correctable extension deformity of MTP, flexion deformity of PIP, no DIP deformity Passive extension w/ standing Neutral w/ non-weight bearing
65
# Define Mallet Toe Which toe is MC affected by hammer/mallet toe? What has been shown to be the primary cause of a MTP deformity w/ hammer toe
Flexion deformity of DIP, normal PIP, MTP 2nd toe due to tight shoes Plantar plate rupture
66
PTs w/ toe deformities can develop corns ? PTs w/ hyper extension of the MTP joint, ? bone is displaced plantarly causing inc of pressure on plantar side
Dorsum of PIP or tip of toe Metatarsal head
67
When assessing toe deformities, ? issue needs to be searched for? When would a neuro work up be indicated for PTs w/ toe deformities
Cavus foot Claw toe w/ high arch
68
How is the presence of a plantar plate rupture assessed for duing a toe deformity PE? What is the mainstay of Tx for these deformities
Anterior drawer/Shock test Roomy box shoe
69
Sesamoiditis is AKA ? D/os of these bones include ? 4
Dancer's Toe Fx Osteonecrosis Arthritis Inflammation
70
What would be seen on PE in sesamoiditis cases How would normal variants be differentiated from Fxs on x-ray?
Pain under 1st MT head and w/ dorsiflexion ROM restricted Normal variants- smooth edges Fx- rough/irregular edges
71
Fungal infections of the nail are called ? What are the two MC microbes that cause this What PO meds can be used
Onychomycosis Trichophyton rubrum/mentagrophytes I/F/K-azole, Terbinafine
72
When are nail fungal infections referred to Ortho? What are clusters of plantar warts called? How are warts differentiated from calluses on exam?
Old/liver can't tolerate PO anti-fungals Mosaic warts Warts are painful when pinched from sides
73
How are plantar warts managed What are some causes of metatarsalgia If these lead to calluses on the sole, the callus is called ?
Paring, keratolytic agents (salicyclic acid) Abnormal metatarsal length Claw/hammer toes Intactable plantar keratosis
74
When assessing metatarsalgia, the discovery of a callus in a line formation indicates ? What test will be positive during PE if there is MTP joint instability
Overload of metatarsal head Anterior drawer (shock test)
75
How are calluses located under a metatarsal head T when associated w/ metatarsalgia Define an Interdigital Neuroma
Plantar condylectomy Morton's neuroma/Plantar interdigital neuroma Perineural fibrosis of common digitalis nerve passing between metatarsal heads Fibrosis occurs from repetitive irritation of nerves
76
Where do Norton's Fibromas MC show? What is the MC presenting issue
3rd web space, between 3 and 4th MT heads 2nd then 1st are lower Plantar pain in forefoot Dysesthesia/paresthesia Rarely night pain
77
What PE test is conducted for interdigital neuromas What may be felt and is indicative of a positive test
Piano key test Compression test Mulder sign- clicking/grinding MT heads
78
What procedure can be Dx and therapeutic of interdigital neuromas? If these are persistent and need surgery, what ligament is released to provide comfort?
Lidocaine/CCS injection proximal to neuroma Division of transverse metatarsal ligament to release plantar nerve
79
What are the 3 stages of an ingrown toe nail Why would x-rays be obtained for Grades 2 or 3
Infalmmation Abscess Granulation- less painful than stage 2 R/o subungual exotosis and osteomyelitis
80
How are each grades of ingrown nails Tx Hallux valgus can cause the great to to shift which direction? What is a common secondary complication seen on PE?
1: warm soak, trimming, socks 2: warm soaks w/ Cephalosporin PO 3: partial/complete nail plate excision Pronate- inward rotation causing medial callus formation 2nd toe over rides that lateral pointing big toe
81
What angles are measured on weight bearing x-rays to assess bunions What is the initial Tx in adults
Hallux valgus angle Intermetatarsal angle Education, shoe modification
82
? is AKA for degernerative arthritis of the MTP in great toe This Dz is the MC ? of the foot and MC ? of the toe
Hallux rigidus Arthritis manifestation 2nd malady, 1st= hallux valgus
83
What do PTs w/ hallux rigidus complain of? What is the hallmark finding of this issue What PE finding indicates a severe problem
Pain from lateral/dorsal osteophytes Pain w/ toe off phase of gait Stiff great toe w/ loss of extension Pain @ mid range of motion
84
How is Hallux Rigidus Tx w/ surgery What procedure is reserved for older and lower demand PTs ? procedure is not recommended
Cheilectomy Arthrodesis Keller procedure Artificial joint
85
Bunionette is sometimes AKA ? This is analogous to a ? What are the common Sxs of Tarsal Tunnel Syndrome
Tailor's bunion Hallux valgus Paresthesia/Dysethesia along medial ankle and is worse after walking
86
How can Tarsal Tunnel be managed If surgery is an option, where is the nerve release done at?
Flat foot + pronation= orthotics can relieve Sxs Distal tunnel released at bifurcation deep to abductor hallucis fascia
87
PTs w/ tarsal tunnel syndrome and pain radiating above the knee or severe pain to light touch need further work up for possible ? What is the MC cause of medial ankle pain of middle aged PTs?
Herniated disk CRPS Posterior tibial tendon dysfunction
88
What are preceding risk factors of posterior tendon dysfunction What are the MC Sxs at presentation
``` Flexible flatfoot CCS injection DM HTN Hx of trauma ``` Pain/swelling at medial ankle
89
What PE finding is seen in posterior tendon dysfunction What would cause Sxs to get better and change the location of the pain?
Too many toe sign- due to forefoot abduction, hindfoot valgus Inability to stand on toes/ball of foot Tendon rupture Lateral ankle pain
90
Posterior tendon dysfunction w/out flat foot is Tx ? What Tx is recommended if flexible flatfoot it present? What Tx is recommended if rigid flatfoot is present?
Cast/brace x 4wks Activity modification NSAID Tendon transfer w/ osteotomy realignment Arthrodesis of hindfoot
91
When are PTs w/ posterior tendon dysfunction referred to Ortho? Pain around the Achilles tendon can arise from what structures?
PTs w/ medial ankle pain Insertional Achilles tendinosis Retrocalcaneal bursitis Haglund syndrome Pre-Achilles bursitis
92
How is a pump bump in posterior heel pain differentiated from Haglund deformity What is the MC cause of posterior heel pain in older PTs?
Prominent calcaneous processes develop bursa irritated by shoes= bump pump on posterolateral aspect of heel Insertion tendonosis w/ enthesopathy, calcification and degeneration tears of tendon
93
How is Achilles tendinosis confirmed w/ PE If it is a retrocalcaneal bursitis, what will be seen on PE?
Squeezing tendon inc pain Swelling, redness and pain anterior to tendon increased w/ squeeze/lateral movement of bursa
94
When should PTs w/ posterior heel pain begin Achilles stretch routines What non-surgical option may alleviate all Sxs in 6wks
After inflammation phase Casting
95
Where does the plantar fascia originate and insert Define the Windlass mechanism
O: medial tuberosity of calcaneous I: proximal phalanges Tightens fascia, Inversion of hindfoot, External leg rotation, Elevates arch
96
What is the MC cause of heel pain in adults What passive movement can inc pain of plantar fasciitis When are x-rays needed?
Plantar Fasciitis Dorsiflexion of toes activates windlass mechanism Systemic Sxs Pain at rest
97
Half of PTs w/ plantar fasciitis develop ? ortho anomoly sen on x-ray If a bone scan were to be done, where would increased uptake be seen? How long can it take for this condition to resolve
Enthesophyte at origin of flexor brevis superior to plantar fascia Medial calcaneal tuberosity 6-12mon
98
What non-surgical Tx is considered for plantar fasciitis after 12mon of non-surgical relief What are the lateral ligaments of the ankle What ligamentous structure holds the distal tibial and fibula together
Focal shock wave Tx ATFL, CFL Anterior tibiofibular syndesmosis
99
What is the MC injury to the subtalar joint What ligament is on the medial side of the ankle What PE finding suggests an injury to the tibiofibular syndesomosis
Inversion injury tearing ligaments Deltoid ligament Squeeze test External rotation test
100
What is the MC adverse outcome of ankle sprains What are the 3 phases of rehab
Joint instability from incomplete rehab 1: NSAIDs, RICE 2: when PT can bear weight w/out pain/swelling, until full ROM and normal strength 3: agility, proprioception, endurance
101
When does the Thompson test hold the most validity for Dx Achilles tears How are these Tx w/out surgery What Tx is recommended for minor and major tears
Within 48hrs of injury Casting/bracing until ankle returns to neutral RICE, immobilization x 5 days
102
Achilles tears need to be evaluated w/in ? time frame What predisposing factor increases DM PTs to ulcerations
24hrs Autonomic dysfunction: dry, scaly, cracking skin on feet/legs
103
If PT w/ ulcer on foot can be probed to the bone, what is the Dx What imaging is used for difficult cases to differentiate between osteomyelitis or Charcot foot?
Osteomylelitis Tech-99 scan
104
If callus develops on the sole of the forefoot, its AKA ? Usually calluses in this location present w/ ?
Intractable plantar keratosis Metarsalgia
105
Where do heloma molle form Where do periungual corn develop
Toe webs Painful lesions at edge of nail, usually w/ mallet toe or improper fitting shoes
106
What procedure is reserved for callues that fail non-surgical Tx? What is a benign thickening of the plantar fascia
Plantar condylectomy Plantar fibroma

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