20: Approach To Ankle And Foot Complaint

Question 1

Three possible injuries with a positive talar tilt test

Answer 1

1. Lateral ankle sprain
2. Calcaneofibular L injury
3. Anterior talofibular L injury

Question 2

What does a positive anterior drawer test signify?

Answer 2

Lateral ankle sprain

Question 3

Possible injury with a positive eversion test

Answer 3

Medial ankle sprain (deltoid L)

Question 4

Two possible injuries with a positive squeeze test

Answer 4

1. High ankle sprain

2. Distal tibiofibular syndesmosis injury

Question 5

Positive Homan’s sign signifies?

Answer 5

DVT

Question 6

Three main types of ankle sprains

Answer 6

1. Lateral
2. Medial
3. Syndesmotic

Question 7

Most common type of ankle sprain

Answer 7

Lateral ankle sprain, Anterior talofibular L

Question 8

Mechanism of injury for a lateral ankle sprain

Answer 8

Foot inversion and/or plantarflexed

Question 9

Medial ankle sprain mechanism

Answer 9

Forced eversion

Question 10

Ligament injured in medial ankle sprain

Answer 10

Deltoid L (but takes a lot of force to actually tear it)

Question 11

Other name for syndesmotic ankle sprain

Answer 11

High ankle sprain

Question 12

Most likely ligament torn in high ankle sprain

Answer 12

Tibiofibular syndesmosis

Question 13

Mechanism for syndesmotic ankle sprain

Answer 13

Forced external rotation of a dorsiflexed ankle

Question 14

Three “grades” of ankle sprains

Answer 14

1. Grade 1: no laxity, minimal ligament damage
2. Grade 2: Mild/moderate laxity
3. Grade 3: complete ligament disruption

Question 15

Treatment for the three grades of ankle sprains

Answer 15

All of them: manage conservatively with NSAIDs, RICE, PT. Grade 3 requires immobilization for 3 weeks, and surgery if unstable

Question 16

Largest tendon in the body

Answer 16

Calcaneal tendon

Question 17

Achilles tendinitis MOI

Answer 17

Repetitive motions -> microtears in tendon -> inflammation (common in athletes)

Question 18

S/S of Achilles tendinitis

Answer 18

Pain/stiffness at tendon insertion, recent increase in activity level, worse with activity

Question 19

Associated test with Achilles tendinitis

Answer 19

NEGative Thompson test

Question 20

Achilles rupture MOI

Answer 20

80% occur during high impact sports

Question 21

S/S of Achilles rupture

Answer 21

Popping sensation at the heel, +/- pain

Question 22

Associated test with Achilles rupture

Answer 22

Positive Thompson test

Question 23

Sever’s disease

Answer 23

Calcaneal apophysitis - inflammation/stress injury to area around apophysis in heel

Question 24

S/S of sever’s disease

Answer 24

Chronic heel pain related to increased activity and growth, pain reproduced over apophysis

Question 25

Four things that can cause a tibiotalar effusion

Answer 25

Injury, arthritis, infection, hemearthrosis

Question 26

Pes planus

Answer 26

Flat feet - loss of longitudinal arch

Question 27

Pes cavus

Answer 27

Exaggeration of longitudinal arch of foot

Question 28

Hammer toe vs claw toe

Answer 28

Hammer toe: flexion at PIP, extension at DIP | Claw toe: flexion at PIP and DIP

Question 29

Hallux valgus

Answer 29

Lateral deviation of big toe that can lead to a prominence on the medial aspect of the MP joint (bunion)

Question 30

What worsens the pain of plantar fasciitis?

Answer 30

First few steps in the morning, prolonged standing, forced dorsiflexion

Question 31

Morton’s neuroma

Answer 31

Inflammation/thickening of tissue surrounding nerves between toes

Question 32

S/S of Morton’s neuroma

Answer 32

Sensation of walking on a marble, palpable in web space -> replicates burning pain with radiation and numbness in toes

Question 33

Associated test with Morton’s neuroma

Answer 33

Mulder’s sign: palpable clicking sensation between third web space as transverse arch is compressed

Question 34

Where is fibular nerve most commonly compressed

Answer 34

Where it wraps around the lateral aspect of the fibular head

Question 35

What can cause fibular nerve compression?

Answer 35

Prolonged lying, crossing legs, ankle sprain, prolonged immobilization in a cast

Question 36

S/S of fibular nerve compression

Answer 36

Weak dorsiflexion and eversion, steppage gait, sensory loss of dorsal foot and lateral shin

Question 37

Charcot foot

Answer 37

Mid arch deformities and collapse of longitudinal arch due to chronic foot inflammation

Question 38

What causes Charcot foot?

Answer 38

Neuropathy, often diabetic

Question 39

What causes diabetic neuropathy

Answer 39

Chronic elevated blood sugar damages peripheral nerves

Question 40

S/S of Charcot foot

Answer 40

Visible collapse of longitudinal arch, warmth, redness, edema, Hx minor trauma

Question 41

What causes gout?

Answer 41

Monosodium urate crystals

Question 42

What joint is most susceptible to gout?

Answer 42

1st MTP

Question 43

What foods cause gout and why?

Answer 43

Meat, shellfish, alcohol -> high in purines, which breaks down to create uric acid

Question 44

What is seen upon joint aspiration of a gouty joint?

Answer 44

Negatively birefringent needle-shaped crystals

Question 45

Pronation vs supination of foot: three actions that create them

Answer 45

Pronation: dorsiflexion, eversion, abduction (Abed) Supination: plantarflexion, inversion, adduction (AdPI)

Question 46

Where does the fibular head glide when the foot is pronated vs supinated

Answer 46

Pronated -> fibular head glides anteriorly | Supinated -> fibular head glides posteriorly

Question 47

When the calcaneus moves into eversion/inversion, where does the talus go?

Answer 47

Calcaneal eversion -> talus goes anterior + medial | Calcaneal inversion -> talus goes posterior + lateral

Question 48

Preference for glide for cuboid, navicular, and cuneiforms

Answer 48

Cuboid: eversion + plantar glide Navicular: inversion + plantar glide Cuneiforms: plantar glide

Question 49

What are the Ottawa Ankle Rules?

Answer 49

Guidelines for when to order X-rays on a pt with ankle pain

Question 50

Ottawa ankle rules: if patient has pain in the malleolar zone

Answer 50

Must have one of the following 1. Bony tenderness at posterior tip of medial or lateral malleolus 2. Unable to bear weight immediately after injury + unable to walk 4 steps in clinic

Question 51

Ottawa Ankle rules: if pt has pain in midfoot region

Answer 51

Must have at least one of the following for an x-ray 1. Bony tenderness at fifth metatarsal or navicular 2. Unable to bear weight immediately after injury + unable to walk 4 steps in clinic