Select Disorders of the Foot and Ankle--78 SLIDES--FOR FINAL Flashcards
Foot and Ankle
• Must provide support and shock absorption and
balance the weight of the entire body
– Dysfunction at FEET may therefore have consequences
throughout ENTIRE BODY!!
• As the most distal site of the body:
– Often affected by VASCULAR disorders
– NEUROLOGIC dysfunction as with Diabetes are often felt first distally at feet
– Vulnerable to TRAUMA and INFECTION
– Many problems often due to lack of support or
inappropriate ________
footwear
Foot and Ankle
1—Lateral Ankle Sprain
Extremely COMMON injuries in the athletic population
• MC injured ligament is: ________ talofibular ligament
• 2nd MC injury is a combination rupture of the ATFL and the calcaneofibular ligament
– Isolated calcaneofibular ligament sprain is rare
• MOI: _______ ___________ sprains
• High recurrence rate: has been reported to be as high as 80%
anterior
Plantarflexion inversion
Foot and Ankle
1—Lateral Ankle Sprain
Grade 1: (MILD) • No laxity • Stable • \_\_\_\_\_\_\_\_\_ tearing or stretching • Single ligament (ATF) • No hemorrhage • minimal swelling • point tenderness • (-) anterior drawer & tilt tests • 2-10 days
Grade 2 (MODERATE) • Mild to moderate laxity • Considered a stable injury • Large spectrum – \_\_\_\_\_\_\_\_\_ tearing of ATF – PARTIAL tearing of ATF and CF • Some hemorrhage • Some local swelling • (+) anterior drawer test • Difficulty with heal raises • 10-30 days
Grade 3 (SEVERE) • Unstable • At least 2 ligaments • Tearing of \_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_ ATF, CF • Early hemorrhage • Swelling both sides • (+) anterior drawer • (+) lateral stability test • Unable to bear weight • 1-3 month
Minimal
Complete
anterior capsule
Foot and Ankle
2—Medial Ankle Sprains
Isolated sprains of the medial ankle ligaments are unusual
–_________ ligament rupture can occur after pronation-eversion, internal rotation, forced plantarflexion, or forced dorsiflexion
• i.e. Stepping on uneven surface
• Chronic medial ligament instability is uncommon
Management • Uncomplicated Grade 1 and 2 sprains can be managed safely without X-rays • Standard approach: – RICE / MICE – Crutches for more serious sprains – Enable patient to bear weight ASAP • Management focus is now \_\_\_\_\_\_\_\_\_
Deltoid
prevention
Foot and Ankle——Fractures
3—Peroneal Tendon Subluxation
SNAPPING over _________ ankle
– Often with sense of WEAKNESS and PAIN
– Often confused with lateral ankle sprain
• History of ankle sprain (recurrent)
– Laxity/instability or ruptured retinaculum
Management:
• Trial of conservative treatment aimed at increasing stability
– Rocker board, strengthening
• If ineffective, surgery may be necessary
lateral
Foot and Ankle——Fractures
Distal Tibiofibular Syndesmotic Injury (DTSF)
4—______________ is made up of:
– Anterior-inferior tibiofibular ligament
– Posterior- inferior tibiofibular ligaments
– Inferior transverse tibiofibular ligament
– Interosseous ligament
• Stabilize the mortise
• Approximately 10% of total ankle sprains
– sometimes called high ankle sprains
• MOI: ________ rotation of foot / internal rotation of leg
– Foot is usually fixed to the ground
• Delayed recovery
– 2-4 months
Common mechanism of syndesmosis injury in football is a blow to the ________ leg of a player who is lying prone on the field, usually in a pile-up ——-Receiving a blow to the_________ leg, thigh, or anterior trunk, with the foot planted, commonly causes rotation of the body in the opposite direction and results in a tibiofibular syndesmosis sprain
Syndesmosis
External
lateral
lateral
Bursitis
1–________ ___________
• Swelling superficial to the Achilles tendon
• Often follows “Pump Bump” aka Haglunds Deformity
– wearing shoes that are TOO TIGHT can cause a bone spur on the back of the heel
(seen often in women who wear high heels)
2–____________
• Swelling deep to the Achilles tendon
• Pain with pressure applied behind the tendon (pinch)
• May be associated with GOUT
Superficial Achilles
Retrocalcaneal
Achilles Tendinitis
Common in runners, cyclists and aerobics • Inflammation of tendon • Pain at posterior ankle • Worse with passive \_\_\_\_\_\_\_\_ and active \_\_\_\_\_\_\_\_\_\_\_ • Squeezing tendon is painful
dorsiflexion
plantarflexion
Peritendinitis of the Extensor Tendons of the Foot and Toes
• Inflammation of the tendon sheath (tenosynovitis)
• Pain over the ______ aspect of the ankle
– Swelling, tenderness and redness may be present
• Pain intensified with active dorsiflexion and toe extension
• Check lacing on shoes to see if too tight a fit
anterior
Tibialis Posterior Tendinitis
1–Pain occurs over the medial midfoot with radiation
to the medial malleolus and posteromedial border of
the distal tibia
– SWELLING may obliterate the posterior concavity of the ___________ malleolus
2—• Palpation of the tendon causes pain
3—• Resisted plantar flexion and
inversion or passive dorsiflexion and eversion intensifies
– Often occurs in overweight, middle aged women and
men as a result of degenerative changes
medial
Peroneal Peritendinitis
• Gradual onset of pain and swelling below the lateral malleolus
• _________ is major cause
– Fracture, inversion injury, direct trauma
– Overuse
• Tenderness over the tendon at the inferior peroneal retinaculum
• Walking barefoot on irregular ground may increase symptoms
• Subtalar motion is often decreased
Trauma
Foot Conditions
Forefoot • 1st metetarsal • 2nd metetarsal • 5th metatarsal • Metatarsals
Midfoot
• Arch
• Tarsal injury
Hindfoot
• Heel
• Achilles(refer to ankle notes)
KNOW ALL
Foot Conditions———– Forefoot
1st Metatarsal
________ _____
• Hyperextension injury spraining the plantar
capsule of the MTP joint (sudden or chronic)
• Pain on dorsiflexion of toe
• Management
– taping the toe to prevent extension
– Ice, rest
– US in water, stiff soled shoe
• If non-responsive, casting may be necessary to decrease
patient activity and immobilize joint to allow for recovery
______ _______
• Beach activities – toe into plantarflexion
• Sprain of dorsal capsule
• Pain in plantarflexion
Turf toe
Sand Toe
Foot Conditions———– Forefoot
1st Metatarsal
______________-
• Pain at the bottom of the 1st toe
• Direct trauma or tension from flexor hallicus
brevis may be cause of irritation
• Onset often follows pushing-off w/ toe or forced dorsiflex’n
• Hallux valgus, flexible footwear and running or
walking on hard surfaces may predispose
• Medial sesamoid is most often involved
• NOTE: These bones may be affected by any
of the bone diseases or other processes:
– RA, Gout, DJD, Fx, Stress Fx, bursitis
Sesamoiditis
Treatment:
• Tape toe to prevent dorsiflexion
• Doughnut shaped padding to relieve pressure
and if halux valgus – tape toe into neutral
– Surgical procedures exist but are rarely needed
Prevention:
• Less flexible shoes
• Reduce time spent on hard surfaces
Foot Conditions———– Forefoot
Hallux Valgus
Lateral deviation (ABduction) of proximal phalanx, 1st toe • Deformity and pain on \_\_\_\_\_\_\_\_\_\_ side of toe • MC in middle aged women • Strong heredity component • Localized bursitis and bunion formation • Abnormal, bony bump Conservative Treatment • Aimed at SLOWING the deviation – Taping toe in neutral with padding over bunion – Keep joint mobile – Big toe box – No high heel • R/O: RA, Gout
medial
Hallux Rigidus
literally means “________________”
• Pain on dorsal surface of first toe
• mild to severe ________ arthritis of the first
metatarsophalangeal joint
• Symptoms can range from mild to disabling
• Elderly pt or athlete with history of capsular sprains
– Often in active, middle-aged individual
• Decreased flexion and extension (painful)
• Presence of tender dorsal osteophyte at first MTP
joint usually confirms the diagnosis
Management: • Mobilize gently • shoes with a wide toe box • Stiff soled shoe or rocker bottom shoe – Artificially creates toe-off-rounded met. bar • Orthotics with medial stiffness • Surgery if non-resolving
stiff great toe
degenerative
Gout
Middle aged or older male patient • Acute attack of 1st toe pain • Joint is red, swollen, warm and very tender – Monoarticular involvement m/c • Metabolic disease: retention of \_\_\_\_\_\_ in body – Cause inflammatory arthritis and eventual bone destruction – May be secondary to chronic renal disease, multiple myloma and diuretic use – Labs: high uric acid level (acute)
Gout
Management
• Use of NSAIDs most effective in early stages
• Address _______ for prevention
– Weight-loss; if indicated
– Limit animal proteins(high-purine; produce uric acid when broken down)
– Increase plant based proteins
– Limit alcohol (interferes with elimination of uric acid)
– High fluid intake (NOT diuretics like coffee, tea, soda)
• Medications
urates
diet
2nd, 3rd and 5th Metetarsal
Traumatic
• Stress fracture
• Metatarsalgia
Non-traumatic
• Interdigital neuroma (Morton’s)
• Freiberg’s (second metatarsal)
KNOW
2nd, 3rd and 5th Metetarsal
Metatarsalgia
Pain at the BALL of the foot
• Increased stress may be evident with callus
• especially over the 2nd met head
Caused By: • Chronic \_\_\_\_\_\_\_\_\_\_\_ of the transverse ligament • Repetitive trauma • Poor shock absorption
Treatment: • Remove or modify cause • Met padding • US, Ice • CMT
stretching
2nd, 3rd and 5th Metetarsal
Morton’s Neuroma
ENTRAPMENT neuropathy with progressive degeneration and deposition of amorphous deposits on the nerve fibers
• Compressed or stretched from repetitive toe flexion and extension
• Perineural fibrosis and demyelination
Common Symptoms and Examination Findings:
• Insidious pain in the ___&_____ intermetatarsal space
• Sharp, burning pain
• Often intermittent pain ( may have long intervals b/w attacks)
• Mass may be palpated
• Transverse compression may increase pain
• Morton’s Test (+)
• Passive extension of toes may increase
pain and/or cause numbness/burning
2nd & 3rd
2nd, 3rd and 5th Metetarsal
Freiberg’s (2nd metatarsal 80%)
—X-ray: will show cortical flattening and collapse
ZZZZZ
2nd, 3rd and 5th Metetarsal
Stress Fracture
Constant pain especially with weight bearing
• History of prolong walking or running
• Possible tenderness to palpation
• ______ -______ is most affected
• Pain increased by squeezing foot together
Management:
• Stiff shoe or rigid orthotic for several weeks
– Pain persists? Crutches for a few weeks
• Athlete? Prescribe _____ _________ to impose non-weight bearing for a few weeks
• Increase calcium/vitamin D intake
2nd met
walking cast
Midfoot Conditions
Medial—— Traumatic
1– Fracture
2– Plantar fascia rupture
MEDIAL----- Non-traumatic – Accessory navicular – Stress fracture – Plantar fascitis – Kohler’s disease – Tarsal tunnel Syndrome
Lateral—— Traumatic
– Fracture
– Cuboid subluxation
LATERAL—- Non-traumatic
– Cuboid subluxation
– Peroneus brevis tendinitis
HERE IT GOES
Midfoot Conditions
Tarsal Tunnel Syndrome—MEDIAL NON-TRAUMATIC
• Insidious onset of numbness and tingling across
________ of foot that is NOT associated with LBP or
leg pain
Possible causes:
• Hyperpronation, swelling, scar tissue, ganglions, tendon
swelling and trauma
Examination:
• (+) Tinel’s
bottom
Plantar Fasciitis—–Midfoot Conditions
Repetitive microtrauma results in chronic inflammation &
degeneration of the plantar fascia fibers
• Sharp _____ pain that travels along the bottom of the inside of the foot
– Often worse when 1st getting out of bed in AM, 1st few steps
– In athlete, during activity, the pain usually decreases as the athlete warms up, but generally returns after activity
Examination:
• Pain with palpation of the medial tubercle of the calcaneus
• Increased pain with passive dorsiflexion and first toe
extension
• NOTE: HEL SPURS are a reaction to chronic fascial tension; NOT the cause of plantar fasciitis
heel
Midfoot Stress Fracture
• Constant, deep, ______ pain
• MC midfoot stress fracture in athletes occurs
in the _________ _________
.
• Worse with weight bearing
• History of prolonged activity
• Bone will be tender to palpation
• Transverse compression may increase pain
Imaging:
• X-ray, bone scan
Treatment:
• Stiff shoe or rigid orthotic for several weeks
• Crutches or walking cast for a few weeks if non-weight
bearing is needed
dull
tarsal navicular
Kohler’s Disease——Midfoot Conditions
• Osteonecrosis of navicular secondary to trauma or
growth variant
• Cause is debated: Normal variant? or avascular necrosis of primary or secondary centers of ossification?
• MC in CHILDREN aged 5-10 years
– Uncommon condition
• Children present with an antalgic limp
• local tenderness of the MEDIAL aspect of the foot over the ________
• Frequently, there is swelling & redness of the soft tissues
• TX: casing (or soft arch supports if mild case)
• Often self resolves in 3-9 months
navicular
Hindfoot
Heel——Traumatic X 2
• Calcaneal fracture
• “Bone bruise”
HEEL-------Non-traumatic X 4 • Fat pad syndrome • Plantar fasciitis • Subluxation • Sever’s disease
KNOW
Hindfoot—–Fat Pad Syndrome
1–Degeneration and loss of fat pad thickness causing a
decrease in shock absorption
2–• Pain in the ______ of the heel
3–• Pain is DECREASED by squeezing the sides of the heel together, approximating the remaining pad
– Helps to differentiate from plantar fasciitis
middle
Hindfoot–Sever’s Disease
• HEEL PAIN in a growing active child
– worse with activity
– Repetitive trauma: common w/ activities requiring
running and jumping
– Repetitive trauma to the weaker structure of the apophysis, induced by the PULL of the _____ ______ on its insertion
• Growth variant of the heel: un-united _______
apophysis
– calcaneal apophysis develops as an independent center of ossification
– Painful inflammation of the calcaneal apophysis
• X-ray: Will appear fragmented
Sever’s Disease——Management:
• Rest, ice (anti-inflammatory agents)
• Stretching program
• “HEEL CUP” or lift or a cushioned shoe insert to take pressure off the heel
• If symptoms worsen, activity modification must be included
• Cast in more severe cases
Achilles tendon
calcaneal
