Other Ankle Disorders Flashcards
Heel pain is usually caused by?
Plantar fasciitis which is often associated with heel spurs
What are the causes of heel pain?
obseity (increased forces)
excessive walking/sports (muscle fatigue)
plantar fascia tightness
flattening of the arch
What are some treatments associated for heel pain?
Orthoses
PT
injection
NSAIDs
very rarely a surgical release in bad cases
What are the subjective findings that we get regarding plantar fascitis?
pain and tenderness on the inside of the heel
- happens during wb
in the morning or after being off your feet for a while and gets worse with activity
What are the objective findings for plantar fascitis?
pain during palpation at the
- inner edge of the fascia
- origin on the anterior edge of the calcaneus
firm pressure is needed to get the max tenderness
What is the typical prognosis regarding plantar fascitis?
~90% who go through treatment will get better in 12 months or so
What are the two bursae that accounts for bursitis in the foot?
retrocalcaneal and subcutaneous calcaneal bursa
What are the causes of retrocalcaneal bursitis?
- constant trauma from shoes and sports
- Gout, RA and ankylosing spondyloarthropathies
- busal impingement
What structures usually impinge the bursa?
between the achilles tendon and BULGING posterior-superior aspect of the calcaneus
What is the subjective findings of a retrocalcaneal bursitis?
posterior ankle pain
pain with walking
What are the signs regarding retrocalcaneal bursitis?
tenderness
lump
inflammation
What is conservative measures regarding retrocalcaneal bursitis?
PT
taking account shoe wear
if so, injections:
- reduce swelling and inflammation
- paired wtih achilles tendon stretching
What is surgical measures regarding retrocalcaneal bursitis?
PUMP BUMP!!
- removing the calcaneal superoposterior prominence
- taking away the damanged buursa
- tendon debridement of the tendon insertion
A hallux valgus (or “bunion”) is caused by?
Big toe moving towards smaller toes but leaves big bump
- the bump is caused by the base of 1st MTP joint deviated laterally
What are some common aetiology regarding a bunion?
Familial
Inappropriate footwear, Toe box (small toe box)
Flatfeet
Long first ray
1st MTP being out of place from the joint articular surface
Metatarsus primus varus
Rheumatoid arthritis
What is metatarsus primus varus?
The 1st MT bone connecting the phalax to the big toe is rotated and angled away from the 2nd MT bone
What is the pathogenesis of a bunion?
- weird angle between the big toe and 2nd toe around > 9 deg while the valgus angle of MTP joint is greater than 20 deg
- forefoot fanning
- joints are unsuitable = osteoarthritis
What are the signs of a bunion?
- there is inflammation of overlying bursa and the skin
- valgus and pronation deformity of the hallux
- painful callus on the 2nd toe
- thick skin over the MT heads
- increased valgus angle at the big toe
Why is there a callus on the 2nd toe?
Second piggy is forced into hyperextension because of that stupid big toe
How are bunions managed?
again, look at the kinetic chain and the planes
- possible x-rays
- any devitations up the chain
What is the aim of a conservative treatment for bunions?
Relieve pressure over the bunion itself
What are the appropriate shoes for bunions?
fitted with low heel and stiff soled shoes
- wide, squared toe box
- more depth to account for DF second toe
What are other treatments for bunions?
Splint - splits the 1st and 2nd toe (a spacer)
Silicone bunion pad to take off the pressure
What are the acute pain management for bunions?
- rest
- moist heat pack
- analgesics
What is the indications for surgical management for bunions?
was not able to handle the conservative management
bad deformity or bunion pain
What are the different categories of flat foot/pes planus?
Flexible (99%)
Rigid (1%)
How do we determine the type of pes planus?
Through the jack test or heel raise test
Check lab notes
Flexible planus foot is indicated by?
INTERNAL longitudinal arch
- GOING AWAY during WB
- BEING SEEN during NWB
What is indicated by the jack test and how is it performed?
By hyperextending the big toe = the internal longitudinal arch is present
What is indicated by the heel raise test and how is it performed?
Patient is in the natural stance then raise their heel
flexible planus = heel goes to varus (in)
What is the etiology of rigid pes planus?
vertical talus from birth
tarsal coalition
Tarsal coalition - abnormal connection of two or more bones in the foot
What are the unsual connections of the tarsal coalition?
calcaneo-navicular
talocalcaneal
- can be bony, cartilagenous or fibrous
What are the symptoms of rigid pes planus?
Foot pain
Hard time walking on uneven surfaces
foot fatigue
peroneal spasm
What is the treatment for rigid pes planus?
4-6 weeks of cast immobilization
surgical:
- resection of connecting bar
- soft tissue interposition
- subtalar arthrodesis
- even triple arthrodesis
What is the purpose of subtalar arthrodesis?
An operating designed to make the arch of the foot more stable but keeping some supination and pronation
- the joints involve are the: talonavicular and calcanocuboid
Which metatarsals are most frequently injured?
The 2nd and 3rd piggies
What is the common reasoning regarding MT stress fracture?
stress or fatigue fracture after cyclical submax loads
ex. running, bad shoes, jogging long distances after not doing so at all
What are the subjective findings of MT stress fracture?
Pain and swelling on WB
Hx of sudden activity increase
running surface change
long walks
What are the objective findings of MT stress fracture?
- swelling
- ecchymosis
- tenderness over the fractured MT
may not show up in imagining for 2-3 weeks
What is Morton’s Neuroma?
tissues get thick around the nerves towards your toes (interdigital nerve entrapment)
- neuropathy
What is the etiology of morton’s neuroma?
trauma
ischemia
entrapment
What is the pathology of morton’s neuroma?
Not a true neuroma but rather a perineural fibrosis of the common digital nerve
Where does the common digital nerve pass through?
Passes between the metatarsal heads
- 3rd and 4th
What is the perineural fibrosis?
swelling and growth of tissues surrounding the nerves that pass between the bones of the foot
What is the subjective findings seen in morton’s neuroma?
- shooting/constant pain when walking
- relieved by rest and taking shoes off
- 3rd and 2nd cleft tenderness
- click on MT squeeze test
cleft - butt crack of piggies
What population does morton’s neuroma common in?
8-10x more in women than men
What is the non-operative treatment for morton’s neuroma?
metatarsal pad
orthoses
injection
excision
What is the recommended shoes for Morton’s Neuroma?
shoes with wide toe box
DO NOT WEAR:
- tight or pointed-toed shoes
- shoes with heels more than 2 inches high
How is post-op Morton’s Neuroma handled?
compression dressing placed with a post-op shoe
How does the dorsal approach affect treatment for Morton’s Neuroma?
Allows for immediate WB and suture removal after 2 weeks
How does the plantar incision affect treatment for Morton’s Neuroma?
slows down WB and suture by adding 2 weeks
- normal shoe by 3-4 weeks
- return to sport in 4-6 weeks
What is the cause of tarsal tunnel?
Posterior tib entrapment since it passes between the flexor retinaculum and medial malleolus
- can be acute or insidious
How is tarsal tunnel diagnosed?
Patient reports of:
- poorly localized burning sensation or pain
- tingling at the medial plantar surface of the foot
- gets worse after movement
- worset at the end of the day
Paresthesia = tingling
What are the objective findings of tarsal tunnel?
- (+) tinel sign
- pain with PROM DF and eversion
- Decreased 2 point discrimination on plantar aspect of foot
- Vagus or valgus deformity of the heel
- Weak foot intrinsics w/ sustained PF of toes
What is the treatment of tarsal tunnel?
local cortocisteroid injections
orthoses
making the foot intrinsics stronk = restore medial longitudinal arch
What is the pathology of turf toe?
Sprain of the 1st MTP joint on big toe
What is the mechanism of injury for turf toe?
Hyperextension and varus/valgus stress on the 1st MTP joint
What are the subjective findings of turf toe?
- red, swollen, stiff 1st MTP joint
- joint can be tender on plantar and dorsal surface
- gait can be limp and be unable to run or jump
- hx of a single DF injury or multiple injuries to the great toe
What are the objective findings of turf toe?
Depending on the grades of severity
What is indicated for a grade 1 sprain for Turf Toe?
minor stretch injury to the soft tissue restraint
- little pain
- minor swelling
- minor disability
What is indicated for a grade 2 sprain for Turf Toe?
partial tear of capsulo-ligamentous structures
- moderate pain
- swelling
- ecchymosis
- moderate disability
ecchymosis = discoloration
What is indicated for a grade 3 sprain for Turf Toe?
complete tear of the plantar plate
- severe swelling
- pain
- ecchymosis
- can’t bear weight normally
What are the basic treatment for turf toe?
R.I.C.E
NSAIDS
Toe taped for DF limit
- but also grade based
Guide: return to sport needs a DF of 90 degrees
What is the timeline for grade 1 turf toe sprain?
return to sport as soon as sx allow
What is the timeline for grade 2 turf toe sprain?
Need 3-14 days of rest
What is the timeline for grade 3 turf toe sprain?
crutches for a few days and up to 6 weeks of rest from activity
What is the specific treatment regarding grade 1 turf toe sprain?
can use narrow athletic tape to immobilize the big toe to restrict pain
- place a firm insert in the shoe to limit movement and promote healing
What is the specific treatment regarding grade 2 turf toe sprain?
may need immobilizing the foot in a brace or walking boot
- allowing several weeks of rest
What is the specific treatment regarding grade 3 turf toe sprain?
IT DEPENDS ON THE SEVERITY
- surgery may be needed if there is a fracture of a bone (!!!)
- damage to the cartilage (the tissue that lines the bones of the joints)
- complete tearing of the tendon
- excessive movement of the joint causes sublux
What is a cuboid syndrome?
When the structures near the cuboid bone are injured = one of the bones is moved or out of place
- often misdiagnosed
- small valid and reliable diagnostic tests
- uncommon (< 3%) after lateral ankle sprain
structures = calcaneo-cuboid ligaments
What is the importance of the cuboid?
The keystone of the lateral column of the foot:
- concave cuboid rest on the convex navicular and lateral cuneiform
How does the cuboid connecting to the navicular important?
The only mid-tarsal that articulates with the navicular
- links the lateral column with the MLA of the foot
Where does the peroneus longus pass through?
slings to the side and down into the fibrous-osseus tunnel in the plantar aspect of the cuboid
What does the aetiology of cuboid syndrome?
Degree and direction of the force of the peroneus then SUDDEN inversion of the midfoot with it being unlocked
= medial and inferior glide of the cuboid
- cuboid will sublux to the middle and down into the plantar direction
tearing of the interosseous ligaments occurs
What is the objective signs of cuboid syndrome?
- pain over the cuboid
- pain in toe-off
- can’t do plyometrics
- pain along the medial arch and/or length of 4th MT
- palpate prominence on plantar lateral aspect of the foot
- limited and painful on DF, INV and EV @ CC joint
- painful dosal glides of cuboid
What are the recommended treatment of cuboid syndrome?
Cuboid whips
cuboid squeeze
mobs with movement
Re-training of intrinsics of the foot = creating stable midfoot in closed chain
rehab of whole kinetic chain
What is the subequent treatment after a cuboid whip?
Peroneal and gastroc stretching
intrinsic/extrinsic foot strengthening
neuro/proprioceptive control exercise
