ankle/foot pathologies Flashcards Preview

Phys: Bone & Gen Med: Ortho > ankle/foot pathologies > Flashcards

Flashcards in ankle/foot pathologies Deck (76):

What is the mc moi for an ankle sprain?

1. 85% - inversion and plantar flexion injury
2. One of the most common sports- related injuries


What ligaments are usually involved in an ankle sprain?

1. Complete or incomplete tear of supporting ligaments surrounding joint
A. Usually involve lateral ligaments
B. Most common anterior talofibular ligament (ATFL)
C. CFL involved in higher grade sprains


What are the sxs of an ankle sprain?

1. Pts report hearing “pop”
2. Eccymosis and tenderness lateral ankle
3. Assess stability
A. Anterior Drawer Sign


What is a grade I sprain?

stable, minimal swelling


What is a grade II sprain?

moderate instability & swelling


What is a grade III sprain?

gross instability, extensive swelling & eccymosis


What landmarks need to be palpated for ankle sprains?

1. Medial and Lateral Malleoli
2. Anterotalofibular ligament (ATFL) and Calcaneofibular ligament (CFL)
3. Deltoid ligament: medial
4. Achilles tendon: posterior
5. Base of fifth metatarsal


What needs to be inspected on a ankle sprain PE?

Inspect for swelling- what side? Medial, lateral, dorsum of foot, posterior


What ROM needs to be assessed for an ankle PE?

active and passive dorsiflexion, plantar flexion, inversion, eversion


What neuro testing needs to be assessed for an ankle PE?

Strength and sensation testing


What special tests need to be performed for an ankle PE?

1. Anterior Drawer test
2. Thompson test
3. Talar tilt


What xray views need to be ordered for an ankle sprain?

1. Ankle X-ray: always THREE views



How is an ankle sprain treated?

1. RICE, air cast, crutches
3. P.T. +/-
4. Refer to Ortho if evidence of fx


How long is the recovery period for an ankle sprain?

1. 6-8 weeks: Grade I and II
2. 8-12 weeks: Grade III
3. Swelling always lasts longer than one would think-
A. can take up to 6 mos. to completely resolve


What is a weber A ankle fracture?

1. distal fibula fx below the mortise
2. Inherently stable fracture
3. Aircast and crutches
4. Cast and crutches
5. May PWB


What is a weber B ankle fracture?

1. at mortise
2. Cast and crutches
3. F/U 7-10 days to recheck x-ray
4. Total cast time 4-6 weeks
5. Total healing time 3-6 months
6. Swelling lasts well past healed bone
7. P.T. when cast d/c’ed


What is a weber C ankle fracture?

1. above mortise
2. Cast and crutches
3. F/U 7-10 days to recheck x-ray
4. Total cast time 4-6 weeks
5. Total healing time 3-6 months
6. Swelling lasts well past healed bone
7. P.T. when cast d/c’ed


What x ray finding indicates surgery?

Wide mortise- tear in tibiofibular ligament: indicates surgery is needed


What is a bimalleolar fx?

Medial and lateral malleolar fx’s


How is a bimalleolar fx managed?

1. Assess mortise, as always
2. Majority of time surgery needed
3. Either within day or two or after 7-10 days in adults depending on swelling/fracture blisters
4. Who needs surgery?- widened mortise, displaced medial malleolus, displaced distal fibula


What is the anatomy and function of the achilles tendon?

Soleus and gastrocnemius muscles converge to form the Achilles tendon, which inserts posteriorly on the calcaneus; Contraction of these muscles, along with the actions of the tibialis posterior and peroneus longus and brevis, causes the foot to plantar flex.


What is the pathophys of achilles tendonitis?

1. Repetitive microtrauma -> degeneration of Achilles tendon -> inflammation of achilles tendon
2. Damaged tendons become calcified, thickened, fibrotic and inelastic


When can an achilles rupture occur?

Rupture can occur when sudden shear stress is applied to an already weakened tendon


What are the two types of achilles tendonitis?

1. Insertional vs. peri-achilles tendonitis
A. Achilles tendon insertion at middle of posterior surface of calcaneus
B. May have asst bone spur
C. Retrocalcaneal bursa: btw Achilles tendon and superior tuberosity of calcaneus


What are the sxs of achilles tendonitis?

1. Pain & stiffness along the Achilles tendon in the morning
A. along the tendon or back of the heel that worsens with activity
B. severe pain the day after exercising
C. thickening of the tendon
-swelling that is present all the time and gets worse throughout the day with activity
2. Burning pain & tenderness approx. 1-5 cm above posterior calcaneus
A. worse w/ activity
B. relieved w/ rest


What are the sxs of achilles rupture?

1. Sudden “popping” sensation: check for rupture
2. + Thompson test- test with pt prone
3. Cannot dorsiflex foot


What is the conservative treatment of achilles tendonitis?

1. Heel lift
2. Aggressive heel cord stretching exercises
3. PT
A. Ultrasound, massage, stretching, strengthening


What is the etiology of achilles tendonitis?

Commonly in males playing basketball, softball- feel like they were kicked from behind at heel and unable to ambulate


What dx studies are used for achilles rupture?

1. MRI to confirm diagnosis if unsure
2. apply Posterior leg splint in slight plantar flexion & Ortho Referral urgently for surgery


Describe the Thompson test

1. Examiner squeezes the calf muscle on the uninjured side -> normal plantar flexion of the foot
2. With a complete Achilles tendon rupture, there is no plantar flexion


How is chronic Achilles tendonitis treated?

1. Chronic Achilles tendonitis on lateral x-ray of ankle may show Haglund deformity
A. Immobilization for 6 weeks (cast, cam-walker)


What are the general characteristics of plantar fasciitis?

1. Very common in runners and overweight pts
2. Caused by microscopic tears in plantar fascia @ calcaneal origin


What are the sxs of plantar fasciitis?

1. 1st step out of bed in morning very painful at heel/arch of foot
2. May get better as day goes on
3. Heel pain
A. Insertion site on medial calcaneus- source of pain


What imaging is needed for plantar fasciitis?

1. X-rays foot- AP and Lateral view
A. Lateral view may show calcaneal spur or fx
2. MRI
A. May reveal calcifications of plantar fascia
B. Usually not needed unless suspect stress fracture of calcaneus


How is plantar fasciitis treated?

2. Stretching exercises are key!
A. Heat prior to exercises and ice after
B. May need PT
3. Cushioned Heel lift/insert
4. Arch supports
5. If resistant, Depo-Medrol injection surrounding medial os calcis- refer to Ortho, very painful


How is chronic plantar fasciitis treated?

1. Chronic PF- surgery can be done
2. Plantar Fascial Release- outpatient sx
A. Crutches for approx 1-2 weeks
B. Reese shoe first 3-6 weeks
C. Recovery: 3-6 months


Define Pseudo-jones fx

1. Base of PROXIMAL fifth metatarsal fx
2. Avulsion fracture -> peroneal brevis tendon tear


How is a pseudo-jones fx treated?

1. Non-displaced or minimally displaced treat conservatively
2. Reese shoe 3-4 weeks
3. Transition to rigid-soled shoe, then any shoe as tolerated
4. F/U 3 weeks, then 6 weeks


Define Jones fx

Base of fifth metatarsal at metaphyseal-diaphyseal junction; more distal as compared to pseudo-jones fx


How is a Jones fx treated?

1. More difficult to heal
A. Refer to ORTHO
B. May require ORIF if malunion/nonunion


How does smoking affect fx healing?

Smoking puts patient at ↑ risk of mal/ nonunion of any type of fx


Where are a stress, jones, and pseudo jones fx in relation to each other?

1. Proximal 5th metatarsal: Pseudo Jones
2. Intermediate 5th metatarsal: Jones Fx
3. Distal 5th metatarsal: Stress fx


What is a Lisfranc fracture-dislocation?

Base of all metatarsals are dislocated laterally


What is the tx for a LisFranc Fracture-dislocation?

Refer to foot orthopedist


Define pes planus

Flat foot, too many toes sign


What are the sxs of pes planus?

1. Pt c/o foot/ankle pain or knee pain (kids)
2. Gait, too many toes sign, tip-toe stance- do heels invert?


How is pes planus treated?

1. OTC orthotics/arch supports
2. Custom-made semi-rigid orthotics
A. Very expensive / ins. not quick to cover
B. Break in period
-wear for few hours @ a time daily


What are the general characteristics of hallux valgus?

1. Most common deformity of MTP joint
2. Result of lateral deviation of proximal phalanx
3. F > M


What is the MC etiology of Hallux valgus?

1. Hereditary
2. Often caused by wearing tight-pointed shoes


What are the sxs of hallux valgus?

1. Metatarsal head pain
2. Deformities of toes
3. Inability to find shoes that fit
4.Obvious deformity on inspection
A. MTP enlargement/angle


What imaging is used for Hallux valgus?

1. X-ray foot
A. Shows valgus deformity of prox phalanx
B. Angle > 15 degrees is abnormal


What is the treatment for Hallux Valgus?

1. Wide shoes, large toe box
2. Bunion pad
3. Surgery if pain not relieved w/ conservative measures


What are the general characteristics of morton's neuroma?

1. Controversies regarding Morton neuroma; likely a misnomer- Not a neuroma
2. Type of nerve compression syndrome-> common digital nerves of lesser toes->perineural fibrosis
3. Result of traction of interdigital nerve against deep transverse metatarsal ligament -> degeneration of nerve and chronic inflammation


What ligament is involved in Morton's neuroma?

Deep transverse intermetatarsal ligament


What are the sxs of morton's neuroma?

1. Sensation of standing on a pebble in your shoe or wrinkle in sock
2. Burning pain in the ball of your foot that may radiate into your toes
A. Tingling or numbness in your toes
3. Sxs resolve w/ rest


What are the risk factors of morton's neuroma?

1. High heels
2. Sports; jogging, snow skiing, rock climbing
3. Foot deformities; bunions, hammertoes, high arches


What are the PE results for morton's neuroma?

1. Palpable lump between metatarsals
2. Lateral compression of metatarsal heads (forefoot) greatly increases Pain
3. Squeeze test @ metatarsal heads elicits pain and paresthesias


What imaging is used and what are the results for morton's neuroma?

1. X-ray of foot is normal
2. Standing AP/Lat/Oblique to r/o bony pathology


What is the treatment for morton's neuroma?

1. Conservative
A. Wide toe box shoes
B. Soft metatarsal pad
C. Cortisone injection around neuroma
2. Surgery- Refer to Podiatrist
A. Decompression surgery, transverse ligament release
B. Excision of neuroma


What is the flexor retinacular ligament?

1. Located posterior & distal to medial malleolus
2. Overlies posterior tibial a,v,n and tendon at medial ankle, region called tarsal tunnel


What is tarsal tunnel syndrome?

1. Compression of post. tibial nerve d/t thick ligament, inflammation causes paresthesias medial ankle down to foot
A. Pes planus, fallen arches can produce this
B. Swelling caused by ankle sprain (should resolve)
C. May be caused by lipoma or ganglion cyst in region or bony spur within tarsal tunnel


Where is the most likely location for a morton's neuroma?

1. 3rd web space: most common location
(btw 3rd &4th toes)
2. 2nd web space, less commonly
3. DO NOT occur in 1st or 4th web space


Who gets Morton's neuromas?

Most often in middle-aged women


What are the sxs of tarsal tunnel syndrome?

1. Pain when ankle @ extremes of dorsiflexion
2. Medial ankle/foot pain
3. Radiating pain along plantar aspect of foot, sometimes up to calf
4. Paresthesias of foot (tingling, burning, numbness or a sensation similar to an electrical shock)
A. Shooting pain in the foot


What needs to be performed on the PE for a tarsal tunnel syndrome pt?

1. Gait
2. Ankle ROM
3. Check for “too many toes sign” and tip toe stance
4. Sensation and strength testing
5. + Tinel sign behind medial malleolus
6. Manual compression for 30 sec may reproduce sxs
7. Compress gastroc/soleus muscles


How is Tarsal tunnels syndrome diagnosed?

1. Usually clinical diagnosis, order x-ray of ankle/foot
2. If palpable mass over region, order MRI to assess
3. May need to order NCS/EMG


What is the treatment for Tarsal tunnel syndrome?

1. Refer to Ortho
3. Steroid injection
4. Orthotics/Shoes
5. All conservative failed: Tarsal tunnel release by foot/ankle surgeon


Define Charcot Neuropathy (Charcot foot)

1. weakening of bones in foot that can occur in pts w/ peripheral neuropathy
A. Injury to foot, +/- fracture, but cannot feel it, continue to walk on it, joint collapses, foot changes shape to a rocker bottom


What is the etiology of a Charcot foot?

1. DM- most common cause of neuropathic (Charcot) arthropathy in US
2. Loss of sensation to a joint can result in chronic, progressive, and destructive arthropathy


What complications can occur from diabetic charcot foot?

1. Deformity
2. Stress fractures
3. Abnormal weight bearing
4. Ulceration and infection


Where can ankle pain be referred from?

1. Lumbar Spine
2. Hip
3. Knee


What are the indications for emergency referral for an ankle/foot pathology?

1. N/v injury
2. Open unstable fx
3. Unreduced joint dislocation
4. Septic arthritis


What are the indications for urgent referral for an ankle/foot pathology?

1. Closed stable fx
2. Reduced joint dislocation
3. Locked joint
4. Tumor


What are the indications for an early referral for an ankle/foot pathology?

1. Motor weakness (neurologic)
2. constitutional symptoms (fever, weight loss)
3. multiple joint involvement


What are the indications for a routine referral for an ankle/foot pathology?

1. Failure of conservative treatment for > 3 months
2. Persistent numbness and tingling in an extremity


What is the treatment for a charcot foot?

1. Total contact cast before collapse
2. Immobilization
3. Surgery after the collapse of the foot
4. Amputation of foot