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Orthopaedic Conditions > Foot/ankle conditions > Flashcards

Foot/ankle conditions Flashcards

1
Q

Noninsertional achilles tendinopathy

A

Pathology that occurs 2-6cm above insertion

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2
Q

Insetional achilles tendinopathy

A

Pathology at insertion

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3
Q

Clinical presentation of insertional/noninsertional achilles tendinopathy

A

Tendon typically swollen, insidious onset of symptoms
In primary stage Pt complain of P following exercise, can develop into P after any activity
Limited dorsiflexion

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4
Q

Treatment of insertional/noninsertional achilles tendinopathy

A

Conservative treatment initially started, typically consists of training modification, RICE, NSAIDs, occasionally immobilisation boot needed
Small heel lift or shock-absorbing orthotic can reduce symptoms

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5
Q

Achilles tendon rupture

A

Most common tendinous rupture in lower extremity
Peak incidence 30-50, middle aged athletes
Sudden pain with audible pop
Common to have more dysfunction than P- will be unable to plantarflex ankle
Refer if- definite rupture, +ve calf sqeuuze test

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6
Q

Causes of ankle sprains

A

Athletic activities, vast majority involve lateral side
ATFL weakest lateral ligament- most likely to be torn
Medial- damage to deltoid ligament, primarily resists eversion

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7
Q

Age groups affected by ankle sprains

A

15-19

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8
Q

Clinical presentation of ankle sprain

A

Vast majority involve lateral side
Rare to see medial sprain
Grade 3 most severe/disabling- often cannot tolerate weight bearing, instability, P on physical assessment, usually describe ‘pop’ sound
Need to identify + localise injured bone and/or soft tissue structures
Acute swelling + ecchymosis occurs instantly after

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9
Q

Prognosis of ankle sprain

A

Prevention preferred over treatment
Taping, bracing, proper athletic shoe wear, and specific training schedules to address strengthening
Usually heal after RICE
Immobilisation in removable walker or crutches will suffice- longer if grade 3
Rehab important
Return to play around 6-8 weeks, if no improvement rethink diagnosis

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10
Q

Grade 3 sprain

A

Severe brusing on both sides- rule out #
Difficulty seeing Achilles tendon due to swelling
Tenderness both sides
Complete tearing of ligaments
Marked instability, unable to weight bear
Almsot complete loss of ROM

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11
Q

Epidemiology of fibula fracture

A

Often occur because of rotational ankle injury
Low energy injury, such as twisting + falling on ankle
Obesity + history of smoking has been correlated

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12
Q

Age groups affected by fibular fracture

A

Over 65

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13
Q

Risk factors of fibular fracture

A

Must ask about comorbid conditions (diabetes, peripheral vascular disease, malnutrition, and tobacco use- important to know as may impact healing period

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14
Q

Clinical presentation of fibular fracture

A

Acute swelling + P
Limited ROM depending on degree of swelling + P
Check for underlying vascular disease of neuropathy- may be neurological compromise if dislocation of ankle, often stretch to peripheral nerves
Proximal leg tenderness, no clear visible ankle swelling may indicate high fibular fracture

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15
Q

Prognosis of fibular fracture

A

Most nondisplaced ankle fractures do not require surgery
Diabetics require 2x healing time
Non-weight bearing for 6 weeks, short leg cast, foot in neutral
Full healing will take 3-4 months
PT to start after 8 weeks, provided Pt not experiencing P
Often continued for additional 6 weeks

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16
Q

Retrocalcaneal bursitis

A

Tissue located between achilles and back of calcaneus
Bursa is horseshoe shaped, 4mm in width 8mm wide
Coated with layer of fibrocartilage

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17
Q

Epidemiology of retrocalcaneal bursitis

A

Often seen in athletes who train uphill, due to extreme dorsiflexion
Compression from shoes

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18
Q

Age groups affected by retrocalcaneal bursitis

A

Usually in younger people, 30s

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19
Q

Clinical presentation of retrocalcaneal bursitis

A

P anterior to achilles
Inflammation of tissue ant to achilles
Haglund deformity usually associated with retrocalcaneal bursitis, enlarged, prominent portion of posterosuperior aspect of calcaneus
Dull aching P, aggravated during start-up activity
Not typically assocuated with acute onset of P- if acutely present should be concerned with achilles rupture

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20
Q

Prognosis of retrocalcaneal bursitis

A

RICE
Stretching gastroc-complex
Heel lifts= elevate heel in shoe, pad plantar aspect of heel
Modification to training
NSAIDs
If unsuccessful- short period of immobilisation in short leg cast (4-8 weeks) may reduce symptoms
Night splints can be worn to improve dorsiflexion + reduce morning start-up P

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21
Q

When to refer for retrocalcaneal bursitis

A

Unresponsive to conservative treatment, achilles tendon rupture, concomitant hindfoot/forefoot deformity

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22
Q

Bunion

A

Enlargement of medial eminence of first MTPJ, where bursa overlying can be inflamed

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23
Q

Hallux valgus

A

Deformity that involves subluxation of 1st metatarsophalangeal Jt resulting in medial deviation of first metatarsal + corresponding lateral deviation of great toe

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24
Q

Epidemiology of bunions/hallux deformity

A

Genetic predisposition
Shoes

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25
Q

Age groups affected by hallux valgus

A

30-50
More prevalent in females due to type of shoes

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26
Q

Clinical presentation of of bunions/hallux valgus

A

P + deformity of first MTP Jt
Increasingly large bump over first MTP Jt
Complaints of how shoe fits
More symptomatic throughout day

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27
Q

Prognosis of bunions/hallux valgus

A

Conservative- accommodate deformity, alleviate symptoms, shoe wear modification
Night splints, custom orthotic inserts, bunion pads, and spacers may be useful
Surgical options post conservative

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28
Q

Metatarsalgia epidemiology

A

History of gradual, chronic, onset rather than acute, traumatic presentation
P usually occurs from prolonged weightbearing activities such as walking, standing and running

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29
Q

Risk factors of metatarsalgia

A

Excess weight
Shoes
Morton’s neuroma
Foot deformities

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30
Q

Clinical presentation of metatarsalgia

A

P on ball of foot
Onset is gradual
Tenderness to palpation at dorsal, central +/or plantar aspect of affected lesser MTPJ
Are of thickened skin/callus at affected JT
Assess ROM of MTPJ

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31
Q

Prognosis of metatarsalgia

A

Alleviate P by decreasing weight bearing
Advised to modify shoe wear + avoid narrow toe box + high heels
Use metatarsal pad to shift pressure

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32
Q

When to refer metatarsalgia

A

Progressive deformity that fails surgical treatment, Pt with recalcitrant P that fails nonsurgical treatment

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33
Q

Plantar fasciitis

A

Band of fibrous tissue extending from plantar calcaneal tuberosity to flexor tendon expansion in forefoot
Supports longitudinal arch of foot

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34
Q

Risk factors/epidemiology of plantar fasciitis

A

Obesity
Work related weight bearing
Decreased ankle dorsiflexion
Runners/athletes more prone, repetitive microtrauma to fascia

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35
Q

Clinical presentation of plantar fasciitis

A

Heel P
Start up P is classic complaint with worse symptoms upon getting out of bed
Usually non-radiating, abates with rest
Stance may reveal foot deformity such as pes planus/cavus
P often exacerbated when toes are passively dorsiflexed (stretches fascia)
Neurological exam necessary to rule out neuropathy from diabetes, radiculopathy or nerve root compression

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36
Q

Prognosis of plantar fasciitis

A

Nonsurgical
Benefits from 3-4 weeks of immobilisation in short leg cast
Well-padded shoes, inserts, night splints, stretching gastroc + plantar fascia
Length of treatment varies

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37
Q

Plantar fasciitis DDx

A

Calcaneal stress #

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38
Q

Interdigital neuritis

A

Refers to symptoms caused by painful branches of common digital nerves most often in second or third web spoces of foot

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39
Q

Epidemiology of interdigital neuritis

A

Traction of metatarsal ligament compresses nerve during normal gait, leaving it susceptible to irritation or direct trauma

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40
Q

Age groups affected by interdigital neuritis

A

Middle aged women- history of wearing shoes with narrow toe box or high heels

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41
Q

Clinical presentation of interdigital neuritis

A

Pin point burning P in second/third web space, worsened by shoe wear
Symptoms often alleviated by removing shoes + massaging toes
May report decreased sensations
P with palpation of plantar surface or lesser metatarsal head + of skin
Reproducible P with palpation of second/third interspace

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42
Q

Prognosis of interdigital neuritis

A

Goal of treatment is to alleviate pressure on nerve
Shoe modification- wide toe box, smaller heel
Orthotic or insole with metatarsal pads placed directly behind interspace allows separation of metatarsal heads, thereby protecting nerve from pressure during walking
NSAIDs will provide some benefits

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43
Q

Congenital talipes (idiopathic club foot) epidemiology

A

Cause unknown
Evidence of chromosomal defect, arrested development in utero, or an embryonic event such as vascular injury

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44
Q

Age groups affected by congenital talipes idiopahtic club foot

A

Incidence of 1-3 per 1000 births
Boys 2x more likely than girls

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45
Q

Risk factors of congenital talipes

A

Family history increases risk by 20-30 times
Boy
Spina bifida

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46
Q

Clinical presentation of congenital talipes

A

Foot curved downwards and inwards, ankle in equinus, heel in varus, forefoot adducted, flexed and supinated
Skin and soft tissue of calf and medial boarder of lateral foot are short + underdeveloped
Deformity obvious at birth
Heel small and high
Assess for associated disorders- hip dislocation, spina bifida

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47
Q

Prognosis of congenital talipes

A

Treatment should be early, preferably within few hours of birth
Repeated manipulation and adhesive strapping
Once corrected, splintage in de-rotation boot is followed until child is 3

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48
Q

Matatarsus adductus clinical presentation

A

Varies form slightly curved forefoot to something resembling mild club foot
Deformity across tarsometatarsal Jt

49
Q

Prognosis of metatarsus adductus

A

90% improving spontaneously or can be managed non-operatively using corrective cast

50
Q

Flat foot (pes planovalgus)

A

Apex of longitudinal arch has collapsed and medial border of foot is in contact with ground
Heel becomes valgus and pronates the foot

51
Q

Epidemiology of flat foot

A

Bones may not have grown properly in womb
As a result of injury

52
Q

Age groups affected by flat foot

A

Arch not formed until 4-6 years
About 15% of population have supple symptomatic flat-feet
Mobile/flexible flat foot- occurs in toddlers as normal stage of development
Stiff/rigid- teenagers

53
Q

Clinical presentation of flat foot

A

Appearance can be normal and without P
Some can be stiff + P
If heels invert and medial arches form when on their toes- likely to be flexible/mobile
Teenagers sometimes present with painful, rigid flat foot

54
Q

Flat feet in adults

A

Ask if they’ve always had flat feet or if its recent onset
More recent deformities may be due to underlying disorders, e.g., RA, or general muscle weakness

55
Q

Prognosis for flat feet

A

Mobile- often disappears after a few years when medial arch development is complete
Rigid- cannot be corrected passively, can be improved by surgery

56
Q

Pes cavus epidemiology

A

Can be past history of spinal disorders
Hereditary

57
Q

Age groups affected by pes cavus

A

Often noticeable by age 8-10, before there are any symptoms

58
Q

Clinical presentation of pes cavus

A

Highly arched foot, toes drawn into claw position
At first position is mobile and deformity cna be corrected passively by pressure under metatarsal heads; as forefoot lifts, toes flatten automatically
Later deformity becomesfixed with toes hyperextended at MTP Jt and flexed at IP Jt
Walking tolerance usually reduced

59
Q

Prognosis of pes cavus

A

Often no treatment required
Pt with significant discomfort may benefit from fitting custom made shoes with moulded supports
If symptoms persist, tendon rebalancing operation may be required

60
Q

Hallux valgus epidemiology

A

Hereditary
Loss of muscle tone in elders
Common with RA

61
Q

Age groups affected by hallux valgus

A

Women 50-70
Appears during late adolescents

62
Q

Risk factors of hallux valgus

A

Type of shoe

63
Q

Clinical presentation of hallux valgus

A

Slightly fan shaped appearance
P pressure may be due to- shoe pressure on bunion, splaying of forefoot + muscle P, associated deformities to lesser toe

64
Q

Prognosis of hallux valgus

A

Encourage wear of shoes with deep toe-box, soft uppers and low heels
Surgical treatment readily offered to older Pt

65
Q

Hallux rigidity

A

Rigidity of MTP Jt

66
Q

Epidemiology of hallux rigidity

A

Local trauma
Osteochondritis dissecans of first metatarsal head
Older people- long standing Jt disorders, e.g., gout, pseudogout, OA

67
Q

Clinical presentation of hallux rigidity

A

P on walking, especially on slopes or rough ground
Hallux is straight, MTPJ feels knobbly
Tender osteophyte on dorsum on MTPJ
Restricted + painful extension

68
Q

Prognosis of hallux rigidity

A

Rocker-soled shoe may abolish P by allowing foot to roll without necessity for dorsiflexion at MTPJ
If walking is painful despite of shoe adjustment, operation advised
Removal of osteopahyte

69
Q

Deformities of lesser toe- hammer toe

A

Isolated flexion deformity of proximal IPJ of lesser toes 2/3
Shoe pressure may produce painful corn
Operative treatment offered if P and difficulty with shoes

70
Q

Deformities of lesser toe- claw toe

A

Deformity of all toes
MTPJ hyperextended and IPJ flexed
Suggests intrinsic muscle weakness
NO cause found
May indicate pes cavus
P in forefoot + under metatarsal head
Bilateral, walking may be impaired
Painful corns + calluses may develop

Metatarsal support to relieves P
Operation

71
Q

Mallet toe

A

Distal IPJ flexed
Toenail or tip of toe presses into shoe, resulting in painful callosity
If conservative treatment doesn’t work, operations is indicated

72
Q

Overlapping toe

A

Often seen when a markedly valgus big toe forces adjacent second toe to find room by sitting on top of hallux
Overlapping toe may fall back into position once hallux is corrected, but sometimes surgery is needed

Overlapping fifth toe is congenital anomaly, if bothersome toe may be straightened by dorsal plasty

73
Q

RA

A

Early on- synovitis in joints, sheathed tendons
Progression- joint erosion and tendon dysfunction, increasingly severe deformities

74
Q

RA in forefoot- clinical presentation

A

P and swelling of MTPJ
Tenderness first localised to MTPJ, later entire foot is painful on pressing or squeezing
Increase weakness of intrinsic muscles and/or Jt destruction

Deformities- flattened arch, hallux valgus, claw toes + prominence of metatarsal heads in sole (Pt may say its like walking on pebbles)

Corns, calluses common
Once deformity is advanced, treatment is surgery

75
Q

RA in ankle + hindfoot

A

Earliest symptoms are P + swelling around ankle
Walking becomes increasingly difficult + later deformities appear
Swelling + tenderness localised to back of medial malleolus
Restricted ROM

Synovitis- splintage helpful to allow inflammation to subside
Injections 2-3 times may reduce inflammation

76
Q

OA epidemiology

A

Almost always secondary to- malunited fracture, recurrent instability, osteochondritis dissecans of talus, avascular necrosis or repeated bleeding with haemophilia

77
Q

OA clinical presentation

A

P + stiffness localised to ankle, particularly when first standing from rest
Ankle usually swollen, palpable ant osteophyte + tenderness along Jt line
Dorsi/plantar flexion restricted
Gait often antalgic
Foot may be turned outwards in stance phase to compensate for loss of ankle movement

78
Q

OA prognosis

A

Painful exacerbation can be managed by analgesics or anti-inflammatory drugs Offloading the Jt can be achieved with use of walking stick, weight loss might be appropriate

79
Q

Gout epidemiology

A

Obesity
High blood pressure
Diabetes
Kidney problems

80
Q

Age groups affected by gout

A

More likely in men
30-50

81
Q

Clinical presentation of gout

A

Swelling, redness, heat and tenderness of MTPJ of big toe
Ankle Jt or one of lesser toe may be affected, especially following minor injury
May resemble septic arthritis

82
Q

Gout prognosis

A

Ant-inflammatory drugs
Until pain subsides foot should be rested + protected from injury

83
Q

Clinical presentation of TB arthritis

A

Begins as synovitis or as osteomyelitis because walking is painful
Swollen ankle
Calf markedly wasted
Skin feels warm
Limited ROM

84
Q

Prognosis of TB arthritis

A

In addition to general treatment a removeable splint used the foot in neutral
If diseases arrested early, Pt allowed up non-weightbearing in a calliper, gradually taking more and more weight and then discard calliper

85
Q

Diabetic foot- factors that affect foot

A
  1. Predisposition to peripheral vascular disease
  2. Damage to peripheral nerves
  3. Reduced resistance of infection
  4. Osteoporosis
86
Q

Diabetic foot epidemiology

A

Complications of long standing diabetes mellitus appear in foot, causing chronic disability

87
Q

Clinical presentation of diabetic foot

A

May be ulceration or gangrene in foot
Peripheral neuroplasty early on, P may complain of symmetrical numbness and paraesthesia
Motor loss may lead to claw-toes with high arches, may predispose to ulceration

88
Q

Prognosis of diabetic foot

A

With regular attendance to diabetic clinic, full compliance with medication, taking advice of foot wear, high level of skin hygiene, etc will ease complications

89
Q

Achilles tendonitis

A

Athletes, joggers and hikers often develop pain and swelling around achilles, due to local irritation
Function inhibited because of P
Condition may come on gradually or rapidly following change of activity

Tendon feels thickened + tender around 4cm above insertion

RICE, NSAIDs initially
When symptoms improve, stretching exercises + muscle strengthening introduced

90
Q

Achilles tendon rupture

A

Rupture probably occurs if tendon is degenerate
Most Pt over 40
While pushing off, gastroc contracts, body contraction is resisted by body weight –> rupture
Unable to rise on tip toes
Soon after, gap can be seen + felt about 5cm above insertion
Simmonds test

91
Q

The painful ankle

A

Except after trauma or in RA, persistent P around ankle usually originates in one periarticular structures or in talus rather than Jt itself

92
Q

Painful ankle- tenosynovitis

A

Tenderness + swelling localised to affected tendon
P aggravated by active movement- inversion or eversion, against resistance
Local corticosteroid injection usually helps

93
Q

Painful ankle- rupture of tibialis posterior tendon

A

P starts suddenly, may be history of snapping tendon
Heel in valgus during weightbearing area around medial malleolus is tender + active inversion of ankle is painful + weak
operative treatment available

94
Q

Painful ankle- osteochondritis dissecans of talus

A

Unexplained P + slight limitation of movement of ankle in a young person
May be due to small osteochondral fracture pf dome of talus
X-ray will show fragment
MRI identifies lesion
If fragment is removed, treatment is successful

95
Q

Painful ankle- avascular necrosis of talus

A

Talus- preferred site of idiopathic necrosis
If P is marked, arthrodesis of ankle may be needed

96
Q

Painful ankle- chronic instability

A

Ligament laxity

97
Q

Painful foot

A

P felt predominately in heel, mid foot ot forefoot
Common causes:
- mechanical pressure- likely from foot deformity
- joint inflamm/stiffness
- localised bone lesion
- muscle strain

98
Q

Painful heel- traction

A

Usually occurs in young boys
Mild traction injury
P + tenderness localsied to achilles insertion

99
Q

Painful heel- apophysitis, Severs disease

A

X-ray shows increased density/irregularities of apophysis
Heel of shoe should be raised a little + strenuous activity restricted for a few weeks

100
Q

Painful heel- calcaneal bursitis

A

Older girls + younger women often complain of painful bumps on back of their heels
Shoe friction causes bursitis
Treatment should focus on footwear, open back shoes, padding of heel
If symptoms warrant, removal of calcaneal prominence may help

101
Q

Painful heel- plantar fasciitis

A

P under ball of heel
Mainly men, aged 30-60
Worse on weightbearing
X-ray shows bony spurs
Sometimes encountered in Pt with inflamm disorders (e.g., gout, ankylosing spondylitis)
Treatment is conservative- NSAIDs, local steroid injections, pad under heel
Can take 18-36 months to heal

102
Q

Painful heel- bony lesions

A

Calcaneal lesions such as infection, tumours, and Paget’s disease can give rise to unremitting pain in heel
Diagnosis usually obvious in x-ray

103
Q

Painful heel- P over midfoot

A

In children, P in midtarsal region is unusual
Possible cause- Kohler’s disease or bony coalition across midtarsal Jt
Kohler’s- may resolve spontaneously
Bony coalition- not all need removing

104
Q

Painful heel- P in forefoot

A

P + tenderness directly under 1st metatarsal head, typically aggravated by walking or passive dorsiflexion of greater toe
Symptoms usually arise from irritation or inflammation of peritendinous tissues around sesamoids
Treatment- reduced weightbearing, pressure pad on shoe

105
Q

Painful heel- Freiberg’s disease

A

P over MTPJ + bony lump, palpable and tender
X-ray shows head to be flattened + wide, neck thick + Jt space increased
Walking plaster or moulded sandal will help reduce pressure on metatarsal head
Persistent symptoms- synovectomy, debridement + trimming of metatarsal heads

106
Q

Painful heel- stress fracture

A

Of 2/3 metatarsal bones seen in young adults after activity
Affected metatarsal shaft feels thick + tender

107
Q

Painful heel- interdigital nerve compression

A

Usually seen in women around 50
P in forefoot, as if walking on pebble, with radiation to all toes
Tenderness localised to one intermetatarsal spaces- usaully 3rd + pressure just proximal to interdigital web may elicit both P + tingling sensation
Secondary thickening of nerve creates impression of ‘neuroma’
Treatment- protective padding, wearing wider shoes, steroid injection may relieve injection may relieve symptoms
Operative options if that doesnt work

108
Q

Ingrown toenail

A

Nail burrows into nail groove; this ulcerates + its wall grows over the nail (embedded toenail)
Cut nail in square shape
If preventative measures don’t work, part of nail responsible for ‘ingrown’ should be ablated, rare to ablate whole toenail

109
Q

Subungual bone growth

A

Nail gradually lifts from bed by an ‘exostosis’ growing on dorsum of terminal phalanx
X-ray shows bony tuberance
‘Exostosis’ should be removed, but reoccurrence is not uncommon

110
Q

Stress #

A

Hx- insidious onset of P, better with rest, overuse injury
SSx- tender to palpation

111
Q

Tibial stress #

A

Most common stress #
Usually involves dominant leg
Repetitive trauma
Less common mid shaft where the ‘dreaded black line’ (where more serious injury occurs)

112
Q

Metatarsal stress #

A

Commonly involves 2/3
Secondary to repetitive stress
Tenderness with metatarsals/Mortons squeeze test
No numbness or tingling

113
Q

Calcaneus stress #

A

Secondary to repetitive trauma
Heel P may mimic plantar fasciitis or retrocalcaneal bursitis/achilles tendonitis
Tenderness with calacaneal side squeeze + percussion
May be P on heel strike
Often has altered gait (soft heel strike)

114
Q

Tarsal tunnel Hx

A

Medial or plantar foot P or parasthesis

115
Q

Tarsal tunnel SSx

A

Tenderness around tarsal tunnel
+ve tinels

116
Q

Tarsal tunnel DDx

A

Lumbar radiculopathy

117
Q

Mortons neuroma Hx

A

Burning P between metatarsals

118
Q

Mortons neuroma SSx

A

Local tenderness
+ve Mortons neuroma

119
Q

Mortons neuroma DDx

A

Lumbar radiculopathy
Metatarsal stress #

Orthopaedic Conditions (11 decks)

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