Rearfoot Pathology--------------exam3 Flashcards
1st met cuneiform exostosis
Clinical presen
Pain w shoe P
Deep aching pain after rest
Palpable mass
Sweelong
Clin
Redness, erythema
EHL tendinitis
Burning, tingling, numbness-MDCN neuritis
Ulceration
1st met cunei exostosis
Conservative treatment
Padding
Shoe modif- extra depth, lacing
Physical therapy
Injection of corticosteroid
1st met cunei exostosis
Surgical treat
Surgical resection (exostectomy)
Arthrodesis- severe DJD
Os trigonum syndrome
- Triangular ossicle located at the posterior aspect of the talus adjacent to the lateral tubercle
- Ossicle can be united to the posterior aspect of the talus by cartilaginous, fibro- cartilaginous, or fibrous tissue
- May be caused as a result of a developmental anomaly or pathologic fracture ???
Os Trigonum Syndrome
Mechanism of fracture is extreme ankle plantarflexion
- Example: ballet dancers
Can predispose FHL tendon to chronic inflammation
Os Trigonum Syndrome
Associated terminology. . .
- An enlarged posterior extension of the lateral tubercle of the talus = Steida’s process
- Fractures of the posterior lateral tubercle = Shepherd’s fracture
Os Trigonum Syndrome
Treatment
- Immobilization
- Physical therapy
- Injection of corticosteroids
- NSAID’s
- Excision
Os Tibiale Externum
Ossicle of varying size, shape, and position which may be found adjacent to the navicular tuberosity
Dwight classification -3 variants
Os Tibiale Externum
Type I
- small ossicle (sesamoid) within posterior tibial tendon
- sesamoid is characteristically round and small in size
- located at a distance from the navicular tuberosity
- usually asymptomatic
Os Tibiale Externum
Type II
- larger then type 1
- oval or semi-circular in shape
- accessory navicular proximal to navicular
- in close apposition to the tuberosity
- it may be attached by cartilage or fibrocartilage, or it may articulate with the tuberosity containing true synovial tissue
- usually most symptomatic
Os Tibiale Externum
Type III
- enlarged tuberosity
- secondary to the accessory ossification center being fused to the tuberosity
- other names:
cornuate navicular, gorilliform navicular - symptoms related bony prominence
Os Tibiale Externum
Clinical Presentation
- pain to palpation to medial prominence
- may palpate motion of bone fragment
- pain upon resistance to supination
- inflammation over the area
shoe irritation, adventitious bursa
Os Tibiale Externum
Treatment
- Padding
- Orthotics
- Immobilization
- Physical therapy
- NSAID’s
- Surgical Excision
Posterior Tibial Tendon Dysfunction (PTTD)
seen in middle-age and elderly females
Painful progressive deformity resulting from a gradual stretch (attenuation) of the PT tendon as well as the ligaments that support the arch of the foot
Most common cause of adult acquired flatfoot deformity
PTTD
- Function (posterior tibial tendon)
- Supports medial arch
- Decelerate STJ pronation(after heel contact)
- Invert and plantarflex the foot
PTTD
The etiology of PTTD is multifactorial
Two categories:
- Traumatic (uncommon)
ex: laceration and avulsion at navicular tuberosity - Degenerative
- Often due to an intrinsic abnormality of the tendon itself
- A chronic inflammatory process, such as tenosynovitis, can cause tendon degeneration, tendon elongation or attenuation, interstitial tearing, and eventually rupture
PTTD
Predisposing Factors
- Overuse
- Pre-existing flatfoot/
pronation - Tenosynovitis
- Systemic inflammatory disease
- Accessory ossicle
- Corticosteroids
- Tendon hypovascularity
- Obesity
- HTN
- DM
PTTD
Clinical presentation
- Usually no history of trauma
- Patient complains of “fallen arches”
- Unilateral progressive flatfoot with calcaneal valgus
- Swelling, warmth and tenderness along tendon
- Lateral calcaneal fibular impingement pain
- may see sinus tarsi syndrome
PTTD
The location of pain can change as the deformity progresses
PTTD
Clinical presentation continued . . .
- “Too many toes sign”
- Unable to perform a single heel rise
- unable invert heels
- Decreased manual muscle testing against resistance
PTTD
“ Too many toes sign”
- forefoot abduction
- posterior view
- more toes are visible
in relation to the lateral surface of the leg on the pathologic side as compared with the normal foot - Usually 1 1⁄2 toes is normal
PTTD
Single heel rise test
- Patient asked to rise up on the ball of the affected foot while the non-affected foot is held off the ground
- Sequence of activation
1. PT tendon- inverts and locks hindfoot
2. Gastrocsoleus muscle group- pulls up heel to
complete heel rise
PTTD
Myerson added a 4th stage
- characterized by valgus angulation of the talus and early degeneration of the ankle joint
