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
PTTD
Conservative Treatment
Immobilization
Physical therapy
NSAID
foot orthoses
Ankle foot orthoses
PTTD
Surgical Treatment
- primary repair
- PT tendon augmentation
- calcaneal osteotomies
- fusions
Sinus Tarsi Syndrome
Sinus tarsi definition:
- anatomic space between the inferior neck of the talus and the superior aspect of the distal calcaneus
Forms part of the subtalar joint
Contains small vessels and nerves, subtalar
ligaments as well as fat and connective tissue
- Hoke’s tonsil
Sinus Tarsi Syndrome
Chronic pain over the sinus tarsi and lateral foot and ankle
Often associated with a sensation of rearfoot instability
Often associated with trauma example: ankle sprain
Sinus Tarsi Syndrome
Non-traumatic cases
- Pes planus/Excessive pronation
- Tarsal Coalition
- Osteoarthritis
- Inflammatory arthritis
Sinus Tarsi Syndrome
Clinical Presentation
- Minimal edema
- Pain elicited by supination
- Pain elicited by direct palpation
- Rapid relief with sinus tarsi block
- Aggravated by ambulation
- Improved with rest
Sinus Tarsi Syndrome
Conservative Treatment
- Physical therapy
- Injections
- NSAIDS
- Orthotics
– limit pronation - Immobilization
Sinus Tarsi Syndrome
Surgical Treatment
- Evacuation of contents of sinus tarsi
- denervate the sinus tarsi
- Arthroscopic examination and debridement of the posterior subtalar joint and sinus tarsi
1st metatarsal- cuneiform exostosis
Saddle bone deformity
Chronic 1st hypermobility- leads to the dorsal jamming at the 1st met-cuneiform joint
Flexible high arched feet- more prone or hypermobile PF 1st ray
