Forefoot Pain

Question 1

Metatarsalgia

􏰀 Physical Exam

Answer 1

􏰀 Generalized pain with palpation just proximal to metatarsal heads plantarly
􏰀 Little to no external signs of inflammation (swelling, redness, increase temperature)
􏰀 Occasionally will palpate a prominent metatarsal and detect fat pad atrophy
􏰀 Can see associated submetatarsal bursitis

􏰀 Pathogenesis
-Excessive pronation
-Collapse of transverse arch

Question 2

Metatarsalgia

􏰀 Diagnosis

Answer 2

􏰀Predominantly history and physical exam

􏰀Radiographs to help exclude other pathology

Question 3

Metatarsalgia

Treatment

ORIO- NIA

Answer 3

Treatment
􏰀Rest (decrease, but don’t stop activity)
􏰀Ice
􏰀OTC analgesics (acetaminophen, ibuprofen, naproxen)
􏰀Stable, supportive shoes (Athletic style)
􏰀Metatarsal pads
􏰀Orthotics
􏰀Surgery to correct metatarsal deformities

Question 4

Classification of Nerve Injury

􏰀 Compression

 -Neuropraxia
 -Axonotmesis

Answer 4

􏰀 Transection
-Neurotmesis

􏰀 Ischemia
􏰀 Radiation
􏰀 Inflammation
􏰀 Degeneration

Question 5

Nerve Injury

􏰀 Neuropraxia
􏰀Most common problem->lower extremity

Answer 5

Distally
􏰀Tibial nerve (tourniquet, casts)
􏰀Peroneal nerve (improper padding during surgery, casts, leg crossing)
􏰀Sural nerve (shoes, casts)
􏰀Intermediate dorsal cutaneous nerve (shoes)

􏰀If proximally (herniated disc)
􏰀Transient or intermittent loss of sensation and/or function (days to weeks )
􏰀Reversible ischemia
􏰀NCV slower until remyelination occurs

Question 6

Metatarsalgia

Answer 6

􏰀 Painful condition of forefoot
􏰀Predominantly plantar
􏰀Mainly “ball of the foot”…can spread to toes
􏰀 Catch all term or wastebasket term
􏰀 Can be self limiting and may respond well to conservative care
􏰀 Aggravated by activity
􏰀 Must make appropriate diagnosis to treat adequately
􏰀Rule out other processes

Question 7

Metatarsalgia 􏰀 Physical Exam

Answer 7

􏰀 Generalized pain with palpation just proximal to metatarsal heads plantarly
􏰀 Little to no external signs of inflammation (swelling, redness, increase temperature)
􏰀 Occasionally will palpate a prominent metatarsal and detect fat pad atrophy
􏰀 Can see associated submetatarsal bursitis 􏰀
􏰀 Pathogenesis
􏰀Excessive pronation 􏰀Collapse of transverse arch

Question 8

Metatarsalgia 􏰀 Diagnosis

Answer 8

􏰀Predominantly history and physical exam 􏰀Radiographs to help exclude other pathology
􏰀 Treatment
􏰀Rest (decrease, but don’t stop activity)
􏰀Ice
􏰀OTC analgesics (acetaminophen, ibuprofen, naproxen) 􏰀Stable, supportive shoes (Athletic style)
􏰀Metatarsal pads
􏰀Orthotics
􏰀Surgery to correct metatarsal deformities

Question 9

Classification of Nerve Injury 􏰀 Compression

Answer 9

􏰀Neuropraxia
􏰀Axonotmesis 􏰀 Transection
􏰀 Neurotmesis 􏰀 Ischemia
􏰀 Radiation
􏰀 Inflammation 􏰀 Degeneration

Question 10

Nerve Injury 􏰀 Neuropraxia

Answer 10

􏰀Most common problem that affects neuronal structures of the lower extremity 􏰀Distally
􏰀Tibial nerve (tourniquet, casts)
􏰀Peroneal nerve (improper padding during surgery, casts, leg crossing) 􏰀Sural nerve (shoes, casts)
􏰀Intermediate dorsal cutaneous nerve (shoes)
􏰀More common proximally (herniated disc)
􏰀Transient or intermittent loss of sensation and/or function for several days to weeks 􏰀Reversible ischemia
􏰀NCV slower until remyelination occurs

Question 11

Nerve Injury

􏰀 Axonotmesis

Compressing too long, from casting

Answer 11

􏰀Crush or severe compression injury
􏰀Demyelination occurs with increased compression time and pressure
􏰀basement membrane intact
􏰀Loss of sensation and/or function for several weeks to months
􏰀Axonal regeneration and remyelination takes place
􏰀NCV slow until healing takes place
􏰀Possible Wallerian degeneration in severe cases resulting in loss of function (permanent)
􏰀Distal segment degeneration similar to transection in severe cases

Question 12

Nerve Injury

􏰀 Neurotmesis (Transection)

From Trauma, surgery

Answer 12

􏰀Least common type of peripheral nerve injury
􏰀Axon and connective tissue are lacerated
􏰀Surgery
􏰀Trauma (knife wounds)
􏰀Lacerated nerve ends are not aligned
􏰀Basement membrane of each nerve cell no longer intact
􏰀Wallerian degeneration takes place
􏰀NCV - no action potential
􏰀Permanent and irreversible w/o intervention (repair)
􏰀Even with repair outcomes are not predictable

Question 13

Nerve injury

Nerve ischemia/infarct

Answer 13

􏰀Vasculitis
􏰀Atherosclerotic disease
􏰀Conduction velocity slowing does not occur
􏰀Nerve degeneration occurs within several days of acute infarct
􏰀Basement membrane intact
􏰀Nerve regeneration is possible
􏰀Must control underlying disease process
􏰀Most common symptomatic area in lower extremity
􏰀Sciatic nerve at mid-thigh level
􏰀Other areas of occurrence in the lower extremity
- peroneal and tibial nerves

Question 14

Nerve Injury

􏰀 Radiation-induced injury

Answer 14

􏰀Mainly seen with radiation treatments for neoplastic diseases
􏰀Pelvic radiation (cervical cancer)
􏰀Delayed presentation; manifests years later 􏰀Progressive weakness
􏰀Sensory loss
􏰀Proprioceptive dysfunction

Question 15

Nerve Injury

􏰀 Inflammatory

Answer 15

􏰀Sensory loss and motor dysfunction 􏰀Infectious
􏰀Herpes Simplex virus
􏰀Epstein-Barr virus
􏰀Herpes Zoster virus (most common)
􏰀Idiopathic
􏰀Lumbosacral plexitis
􏰀Diabetes
􏰀Diabetic radiculopathy
􏰀Diabetic amytrophy
􏰀Dorsal root ganglion
􏰀Sjogren’s syndrome

Question 16

Nerve Injury

􏰀 Degeneration

Answer 16

􏰀Distal (most common)
􏰀Gradual distal to proximal degeneration
􏰀Longest nerves affected first
- Distal-most segments of nerve are most vulnerable to metabolic pathology and toxic issues
􏰀Axonal polyneuropathies
􏰀Proximal (rare)

Question 17

14 Nerve Injury

􏰀 Common Symptoms

Answer 17

Pain (burning, shooting)

Paresthesia (numbness, tingling and burning)

Pruritis

Motor function loss

Anesthesia (numbness)

Question 18

Most common cause of lower extremity peripheral n syndromes

Answer 18

L5- back pain radiating down to lateral leg to foot

Question 19

Nerve Injury

􏰀 Autonomic involvement

Answer 19

􏰀Involvement of autonomic nerves may cause trophic skin changes

􏰀Thin, red, dry and shiny skin

􏰀May lead to ulceration or slow wound healing
-Abnormal nerve supply to arterial smooth muscle

Question 20

Physical Exam - Nerve Injury

Answer 20

􏰀 Valleix Sign
􏰀Pain radiating proximal and distal upon palpation or percussion of the entrapped nerve

􏰀 Tinel’s Sign
􏰀Distal tingling or radiation of pain upon percussion of the entrapped nerve

Question 21

Common Nerve Entrapments or Compressions

􏰀 Morton’s – common digital nerve
􏰀 Joplin’s – medial proper digital nerve to hallux

Answer 21

􏰀 Anterior Tarsal Tunnel – deep peroneal nerve
􏰀 Lemont’s Nerve – superficial peroneal nerve (intermediate dorsal cutaneous nerve)

􏰀 Sural Nerve
􏰀 Tarsal Tunnel Syndrome – posterior tibial nerve
􏰀 Common Peroneal Nerve

Question 22

Morton’s Neuroma

􏰀 Aka – Interdigital Perineural Fibrosis

Answer 22

􏰀 Nerve compression syndrome involving the common digital nerves

􏰀 Tumor-like mass of neurilemmal cells and scar tissue along the course of an intact nerve

􏰀 Not a neoplasm, but a reaction to trauma

􏰀 A form of mechanical nerve entrapment

Question 23

Morton’s Neuroma

􏰀 3rd common digital nerve in 3rd interspace most common

Answer 23

􏰀Largest digital nerve as part of the medial and lateral plantar nerves combine

􏰀80-85%

􏰀2nd interspace 15-20%

􏰀Other interspaces consider other etiologies

􏰀 Most common in women and middle age

Question 24

Morton’s Neuroma- Anatomy. ****

􏰂 Nerve passes deep to DTIL

􏰂 Nerves then bifurcate into the toes

Answer 24

Etiology?: Nerve compressed by DTIL or adjacent metatarsal heads

Question 25

Morton’s Neuroma

Answer 25

􏰂 Intermetatarso-phalangeal bursa is believed to be bigger in this interspace

Question 26

Morton’s Neuroma-Symptoms 􏰂 Pain in the forefoot can radiate to toes or proximally into foot causing burning or tingling 􏰂 Can also be a sharp pain, stabbing pain or numbness 􏰂 “Pebble” or “sock bunched up”

Answer 26

􏰂 Pain usually worse with walking and toe-off 􏰂 Can be worse with high heeled shoes or shoes with narrow toe-box and with activity 􏰂 Predilection for women 􏰂 Patients report they can only get relief by removing shoes and rubbing the foot

Question 27

Morton’s Neuroma-Diagnosis 􏰂 Based primarily on H n P – clinical diagnosis - Do not see redness, increase temperature, or swelling 􏰂 Neurological exam - Decreased sensation on adjacent sides of the toe

Answer 27

􏰂 Mulder’s Sign- compress med to lat, hearing clicking sound 􏰂 Pencil test 􏰂 Palpation plantar aspect of metatarsal interspace yields pain 􏰂 Dorsiflexion of the toes may cause pain 􏰂 Lidocaine injection as diagnostic block

Question 28

Mulder’s Sign

Answer 28

􏰂 Palpable click in interspace with compression of adjacent metatarsal heads 􏰂 Foot is squeezed (medial to lateral) at metatarsal heads and interspace is palpated 􏰂 (+) sign: palpable click of swollen nerve on metatarsals with reproduction of symptoms

Question 29

Pencil Test

Answer 29

􏰂 Pencil, pen or other simple device is placed in web space – downward pressure applied 􏰂 Pain elicited with neuroma 􏰂 May use finger in web space

Question 30

Sullivan’s Sign

Answer 30

􏰂 Clinical the toes adjacent to the neuroma splay apart 􏰂 Visible radiographically 􏰂 Explanation: Neuroma mass displaces digits apart 􏰂 Not reliable as a sole means of diagnosis - Soft tissue (capsular) weakness can also result in digital position changes

Question 31

Morton’s Neuroma-Diagnosis When ordering MRI, order w contrast*****

Answer 31

Check for negative findings as well as to rule out other pathology 􏰂Pain under metatarsal heads 􏰂Pain to palpation of MTPJ’s 􏰂Pain on ROM MTPJ’s 􏰂Pain with attempt to sublux MTPJ Bursa-Neuroma Relationship 􏰂Trauma ->Inflammation 􏰂Inflamed bursa ->Pressure on nerve ->Inflamed nerve 􏰂2nd, 3rd webspace more likely than 4th

Question 32

Morton’s Neuroma-Imaging

Answer 32

􏰂 Radiographs – r/o other pathology 􏰂 MRI – r/o other pathology 􏰂 Bone scan – r/o other pathology 􏰂 Ultrasound – operator dependent (more useful)

Question 33

Differential diagnosis

Answer 33

􏰂Tarsal tunnel syndrome 􏰂 Peripheral neuritis/neuropathy 􏰂 RA, Capsulitis 􏰂 ST Tissue tumor of the forefoot 􏰂 Metatarsal tumor / stress fracture 􏰂 Calluses associated with HT and claw toes 􏰂 Freiberg's 􏰂 Bursitis

Question 34

Joplin’s Neuroma

Answer 34

􏰂 Compression and/or entrapment neuropathy of the plantar proper digital nerve to the hallux 􏰂 Uncommon in literature 􏰂 Perineural fibrosis of the nerve 1st described in 1971 by Joplin

Question 35

Joplin’s Neuroma

Answer 35

􏰂 Condition originally described in conjunction with HAV deformity 􏰂 Repeated trauma to nerve from shoegear and pressure on medial eminence of bunion deformity cause symptoms 􏰂 Pain and numbness or tingling in medial aspect of hallux

Question 36

Neuroma Treatment 􏰂 Conservative care:

Answer 36

􏰂Success of therapy: Length of time symptoms | 􏰂Some believe that conservative therapy will never make patient completely asymptomatic

Question 37

Neuroma Treatment 􏰂 Conservative care:

Answer 37

``` 􏰂Padding/Offloading 􏰂Shoe modification 􏰂Orthotics 􏰂 Strapping/Taping 􏰂Injection 􏰂Corticosteroid 􏰂Sclerosing Alcohol Solution ``` (newer-small 1ml+ local anesthetic-> injecting this causes extensive sclerosing); 7-10 injections in 7-10 wks ; when failed, surgery recommentded

Question 38

Neuroma Treatment 􏰂 Surgical excision of neuroma ICES

Answer 38

􏰂 Incision of DTIM ligament (decompression) | 􏰂 Cryosurgery (cryogenic neuroablation) 􏰂 EDIN procedure (endoscopic decompression interdigital neuroma)

Question 39

Complications Re-visited DC

Answer 39

􏰂Recurrent neuroma (stump neuroma) 􏰂 CRPS 􏰂 Digital deformity secondary to transection of a lumbricale or interossei tendon

Question 40

Anterior Tarsal Tunnel 􏰂 Deep peroneal nerve RATS passed DEEP TIGHT Door

Answer 40

􏰂 Rare 􏰂 Anterior aspect of the ankle midway between the malleoli 􏰂 Trauma/Contusion to ankle or dorsum 􏰂 Soft tissue mass (ganglion) 􏰂 Dorsal beaking/osteophyte formation at T-N or Naviculo-cuneiform joints 􏰂 Tight fitting rim/strap/laces from shoe

Question 41

Anterior Tarsal Tunnel | 􏰂 Pain on anterior ankle (where foot meets leg)

Answer 41

􏰂 Minimal weakness 􏰂 Sensory disturbance – 1st interspace area 􏰂 Physical Exam: Limited abnormal findings 􏰂 Foot type: Pes cavus 􏰂 NCV: prolonged distal motor latency 􏰂 EMG: abnormal EDB

Question 42

Lemont’s Nerve 􏰂 Superficial peroneal nerve - Intermediate dorsal cutaneous and medial dorsal cutaneous nerves SUPER INTEResting SIT

Answer 42

􏰂 Subject to trauma due to superficial nature 􏰂 Intermediate dorsal cutaneous nerve may be injured in severe inversion ankle sprain 􏰂 Tight fitting shoes

Question 43

Sural Nerve

Answer 43

􏰂 Superficial as it courses posterior to lateral malleolus 􏰂 Subject to external and internal compression at that point 􏰂Internal – Peroneal tendon pathology, lipomas, cysts 􏰂 External – shoe pressure 􏰂 May be entrapped at base of 5th metatarsal and at CC joint

Question 44

Common Peroneal Nerve Courses around neck of fibula an through peroneus longus muscle belly

Answer 44

􏰂 May be compressed at either site 􏰂 Compression usually before it splits into deep and superficial branches 􏰂 Causes: external pressure on nerve from prolonged lying (surgery), crossing legs, prolonged squatting, casts

Question 45

Common Peroneal Nerve Acute foot drop 􏰂Limp foot; difficulty walking 􏰂Trip over foot unless they compensate by flexing hip = Steppage gait

Answer 45

􏰂 Parasthesias/sensory loss over dorsal foot/lateral shin 􏰂 Rarely painful 􏰂 Normal reflexes 􏰂 EMG and NCV can be useful in diagnosis

Question 46

Common Peroneal Nerve 􏰂 Treatment difficult

Answer 46

􏰂Remove compression ( if it's not too late) 􏰂AFOs ( if it's late)(n is permanently damaged) Drop foot, unable to DF, -etc: electrical signal band -more rigid drop ft->surgery 􏰂Physical therapy 􏰂Prognosis: depends on degree of pathology 􏰂Complete lesions: No recovery 􏰂Incomplete lesions (mildly preserved strength): Full recovery

Question 47

Diagnostic Testing

Answer 47

􏰂 EMG (Electromyography) 􏰂 Nerve conduction studies (NCS)=Nerve Conduction Velocity (NCV) 􏰂 Imaging -MRI first line in lumbosacral spine disease, sensory loss over dorsal foot, weakness of L5 muscles -CT and Plain film radiography 􏰂 Serologic testing -Limited value -HbA1c, fasting blood glucose, Lyme titers 􏰂 Lumbar Puncture -Unusual presentations

Question 48

Stress Fracture

Answer 48

...result from cumulative repetitive forces insufficient to cause an acute fracture, but which eventually lead to stress failure of the involved bone.” (Sarrafin, 1991) 􏰂 Stress fractures are divided into fatigue fractures and insufficiency fractures 􏰂 Breithaupt 1855 first described

Question 49

Stress Fracture | 􏰂 Break in bone caused by repetitive stress injury/trauma

Answer 49

Wolf’s Law 􏰂Dynamic Tissue 􏰂Osteoclastic activity > osteoblastic activity 􏰂Microfracture

Question 50

Stress Fracture – Risk Factors Anatomic 􏰂Abnormal sagittal plane position of metatarsals 􏰂Long 2nd metatarsal 􏰂Equinus 􏰂Pes planus foot structure 􏰂Limb length discrepancy

Answer 50

Physiologic 􏰂Obesity 􏰂Osteopenia (amenorrhea, malabsorption syndromes, bariatric surgery, poor nutrition, medication (steroids), EtOH (chronic alcohol) 􏰂Age

Question 51

Stress Fracture – Risk Factors External factors Ppac

Answer 51

􏰂Poorly fitting shoes 􏰂Abrupt increase in training volume/intensity 􏰂Change in training surface 􏰂Post-surgery

Question 52

Stress Fractures Insufficiency Fractures * **Normal bone-> stress fracture * **Osteoporosis-> insufficient fracture

Answer 52

``` 􏰂Osteoporosis 􏰂Rheumatoid arthritis 􏰂Osteomalacia 􏰂Fibrous Dysplasia 􏰂Paget’s disease 􏰂Osteogenesis imperfecta 􏰂Hyperparathyroidism 􏰂Scurvy 􏰂Irradiation ```

Question 53

Metatarsal Stress Fractures (2,5,1) 􏰂 March Fracture 􏰂Military recruits

Answer 53

􏰂Break in cortex of bone 􏰂Repetitive stress 􏰂Possible overt fracture without treatment -Sagittal plane deformity most problematic 􏰂 2nd Metatarsal most common followed by 3rd 􏰂Metatarsal neck

Question 54

Metatarsal Stress Fractures 􏰂1st metatarsal 􏰂Rare 􏰂Metaphyseal-Diaphyseal junction

Answer 54

􏰂5th metatarsal (more common than 1st, less common than 2nd) 􏰂Proximal metatarsal 􏰂Worse prognosis 􏰂Nonunion 􏰂More aggressive treatment

Question 55

Metatarsal Stress Fractures

Answer 55

􏰂 No radiographic evidence until 10-21 days post symptoms 􏰂 Bone scan and MRI show almost immediately *** order bone scan- show hot spots, some level of ionization

Question 56

Metatarsal Stress Fractures Symptoms

Answer 56

􏰂Gradual worsening of pain in forefoot 􏰂Onset with new activity 􏰂Sharp pain in forefoot aggravated by ambulation 􏰂Pain to palpation localized dorsally 􏰂Diffuse edema dorsally with possible focal increase in temperature 􏰂Axial load elicits pain(weight body pushing you down) 􏰂Helps rule out isolated soft tissue injury

Question 57

Metatarsal Stress Fractures Diagnosis

Answer 57

􏰂Clinical examination 􏰂Serial radiographs 􏰂Bone scan 􏰂MRI

Question 58

Metatarsal Stress Fractures Differential Diagnosis

Answer 58

􏰂Muscle/tendon strain 􏰂Toe or metatarsal shaft fracture 􏰂Turf toe 􏰂Metatarsalgia 􏰂Sesamoiditis/Sesamoid fracture 􏰂Morton’s neuroma 􏰂Plantar fasciitis 􏰂Ligament sprain 􏰂Osteomyelitis 􏰂Bone cyst/tumor

Question 59

Metatarsal Stress Fractures Treatment 􏰂Basic analgesia -Caution with NSAIDs and fracture healing BARSS

Answer 59

BARSS 􏰂Activity restriction 􏰂R.I.C.E. therapy 􏰂Surgical shoe or stiff soled shoe 􏰂Supportive cushioned running shoe

Question 60

Freiberg’s Infraction/Disease 􏰂 infraction, incomplete fracture without displacement of fragments 􏰂 Osteochondritis of the 2nd, 3rd or 4th metatarsal head

Answer 60

􏰂 Trauma vs. primary avascular necrosis of the metatarsal head, or combination 􏰂 F > M, (>11-13yrs) 􏰂 Flattening and widening of metatarsal head 􏰂 Unilateral, 2nd metatarsal most common 􏰂 External stress resulting in avascular bone

Question 61

Freiberg’s Disease Clinical presentation 􏰂Forefoot pain worse at end ROM

Answer 61

􏰂Gradual onset, dull aching pain 􏰂Pain worse with ambulation 􏰂Most pain palpable plantarly at metatarsal head 􏰂Radiographic findings -Early phase subchondral fractures may be seen - As it progresses resorption of necrotic bone occurs - Flattening of metatarsal head occurs with deformity

Question 62

Freiberg’s Disease Treatment 􏰂Can be self limiting or asymptomatic *** dont fuse metatarsal????.

Answer 62

􏰂Early catch->short term immobilization 􏰂Later stages, metatarsal bar or pad 􏰂NSAIDs 􏰂Surgical if conservative fails

Question 63

Sesamoiditis

Answer 63

􏰂 Inflammation of the region surrounding the sesamoid apparatus 􏰂 Repetitive, excessive pressure of the forefoot 􏰂 Ballet dancers, baseball catchers, construction workers

Question 64

Sesamoiditis Symptoms

Answer 64

􏰂Gradual onset 􏰂Mild ache that increase to intense throbbing over time 􏰂Rarely bruising 􏰂Pain increased with activity/walking and running 􏰂Localized edema occasionally 􏰂Sesamoid may have some damage

Question 65

Sesamoiditis 􏰂 Clinically

Answer 65

􏰂Localized signfiicant pain to the sesamoid on plantar palpation 􏰂Exacerbated by hallux dorsiflexion 􏰂Diagnosis is by H n P 􏰂Radiographs used to R/O fracture or other pathology ( not helpful)

Question 66

Sesamoiditis Treatment 􏰂Insole with modification cutout for sesamoid relief (Dancer’s pad) 􏰂Ice masssage 􏰂NSAIDs JOIN ABC InS

Answer 66

􏰂Orthotics, soft pads, stiff soled shoes, avoid high heels 􏰂Joint immobilization with strappings 􏰂Activity modification 􏰂BK cast 􏰂Corticosteroid injection 􏰂Surgery

Question 67

Sesamoid Fracture | 􏰂 Many overlapping symptoms with sesamoiditis, often times more intense

Answer 67

􏰂 Substantial swelling 􏰂 More likely to have ecchymosis 􏰂 Limited and painful ROM of 1st MPJ 􏰂 Usually correlates with a traumatic incident

Question 68

Sesamoid Fracture | -Radiographs: AP, MO, FF Axial

Answer 68

- Determine between fracture and bipartite sesamoid 􏰂25% of population, of that 85% -bilateral 􏰂Tibial sesamoid more often bipartite 􏰂Bipartite usually has smooth, distinct lines and the two pieces together usually larger then the other sesamoid - Bone Scan or MRI may be needed

Question 69

Sesamoid Fracture Treatment 8 BOCS N Tax

Answer 69

``` 􏰂NSAIDs 􏰂BK casting 􏰂> 8 weeks 􏰂Treatment parallels sesamoiditis treatment options -Off-loading orthotic -Corticosteroid injection -Surgical ```

Question 70

Hallux Limitus/Rigidus Normal ROM 1st MPJ dorsiflexion 65o Types:

Answer 70

􏰂Functional – decreased ROM with loading of 1st metatarsal but normal ROM in open chain kinetics 􏰂Structural – decreased ROM with loading of 1st metatarsal and in open chain kinetics

Question 71

Hallux Limitus/Rigidus Symptoms:

Answer 71

􏰂begin in early adult life with discomfort (during daily and athletic activities ) 􏰂As time goes on, more destruction leads to increase in pain, immobility, joint destruction, thus converting Hallux Limitus to Hallux Rigidus

Question 72

Hallux Limitus/Rigidus Etiologies -Structural 􏰂Metatarsus primus elevatus 􏰂Long 1st ray 􏰂Short 1st ray 􏰂Hypermobility of the 1st ray

Answer 72

- DJD (degenerative joint ds) - Iatrogenic – complication from a previous surgery - Trauma - Gout - Infection - Osteochondritis dissecans (lesions)

Question 73

Hallux Limitus/Rigidus 􏰂 Radiologic Findings SLOT SUJO

Answer 73

􏰂Joint space narrowing 􏰂Subchondral sclerosis (eburnation) 􏰂Osteophytosis 􏰂Subchondral cyst formation 􏰂Loose body (“joint mouse”) 􏰂 These findings are consistent with osteoarthritis

Question 74

Hallux Limitus/Rigidus 􏰂 Treatment LOSS PR

Answer 74

􏰂Reduce acute inflammatory phase 􏰂Padding and strapping 􏰂Stiff sole shoe 􏰂Orthotic control – Morton’s extension 􏰂Long term conservative care usually is inadequate 􏰂Surgery

Question 75

Digital Deformities

Answer 75

􏰂 Hammertoes 􏰂 Clawtoes 􏰂 Mallet toe 􏰂 Adductovarus 4th and 5th digits

Question 76

Etiology 􏰂 The main causes of a hammertoe fall into 3 dynamic categories:

Answer 76

􏰂Flexor stabilization 􏰂Flexor substitution 􏰂Extensor substitution

Question 77

******Flexor Stabilization | 􏰂 most common cause of hammertoes

Answer 77

􏰂 occur with pronated foot type-cause flexors to fire longer and harder 􏰂 seen in late stance phase of gait 􏰂 associated with adductovarus of 4th and 5th digit due to loss of mechanical advantage of quadratus plantae 􏰂 weak interossei

Question 78

Flexor Stabilization Treatment 􏰂 arthroplasty is usually the mainstay of treatment (Arthroplasty- removing a piece of joint, but not fusing together) (Arthrodesis- fusing joint)

Answer 78

􏰂 corrective orthotics are needed to neutralize the etiology of pronation

Question 79

Flexor Substitution | 􏰂 least common cause of hammertoes

Answer 79

􏰂 occurs in a supinated foot type 􏰂 seen in late stance phase of gait 􏰂 flexors gain mechanical advantage 􏰂 occurs with weak triceps surae complex **

Question 80

Flexor Substitution Treatment | 􏰂 tendon transfer to strengthen the weakened triceps surae

Answer 80

􏰂 arthrodesis of the digits 􏰂 simple arthroplasty would not be enough to neutralize the deforming force

Question 81

Extensor Substitution | 􏰂 seen in swing phase of gait

Answer 81

􏰂 extensors>lumbricales 􏰂 MPJ dorsal contraction >90 􏰂 begins as flexible and progresses to rigid 􏰂 reduced early on with weight bearing 􏰂 due to pes cavus, ankle equinus, lumbrical weakness, EDL spasticity and pain & TA weakness

Question 82

97 Extensor Substitution Treatment

Answer 82

􏰂 arthrodesis would be the procedure of choice 􏰂 with a flexible deformity, a Hibbs tenosuspension would be helpful

Question 83

****Hammertoes (exten MTP->flex PIP-> ext DIP) *** claw(ext-flex-flx) 􏰂 Extension contracture of Metatarsalphalangeal Joint (MPJ)

Answer 83

􏰂 Flexion contracture of the Proximal Interphalangeal Joint (PIPJ) 􏰂 Extension contracture of the Distal Interphalangeal Joint (DIPJ) For the Hallux the contracture is only at the MPJ and Interphalangeal Joint (IPJ)

Question 84

Hammertoes Etiology 􏰂Idiopathic Under SLIIM shoE

Answer 84

􏰂Excessively plantarflexed metatarsal 􏰂Shoe pressure 􏰂Intrinsic muscle imbalance 􏰂Long and short extensors dysfunction 􏰂MPJ instability 􏰂Underriding hallux secondary to HAV

Question 85

Hallux Hammertoe 􏰂 Etiology

Answer 85

􏰂Imbalance between hallux extensors and flexors 􏰂Loss of function of flexor hallucis brevis secondary to removal of both sesamoids

Question 86

Clawtoes Same as hammertoe etiologies

Answer 86

􏰂 Extension contracture of the MPJ 􏰂 Flexion contracture of the PIPJ 􏰂 Flexion contracture of the DIPJ

Question 87

Mallet Toe | Straight ->DIPJ is flexed

Answer 87

Mallet Toe 􏰂 Flexion contracture of the DIPJ 􏰂 Relatively normal position of the PIPJ and MPJ 􏰂 Not very common Etiology 􏰂Imbalance between the extensors, flexors and intrinsic muscles to the digit

Question 88

Adductovarus Digital Rotation

Answer 88

􏰂 Adduction, varus rotation and some flexion of the 3rd, 4th and 5th toes 􏰂 Deformities are greater distally 􏰂 Severity: 5th > 4th > 3rd toe

Question 89

Adductovarus Digital Rotation 􏰂 Etiology

Answer 89

􏰂Pronated foot late in midstance and propulsive period of gait leads to forefoot abduction relative to the rearfoot. This creates an abnormal medial posterior pull on the long flexors at the distal phalanges. Final result over period of time is adductovarus rotation.

Question 90

Pathologies of Digital Deformities 􏰂 Pathology i HAUS

Answer 90

􏰂Heloma dura -dorsal, lateral aspect, callus looking 􏰂Adventitial bursa - blister under the skin 􏰂Ulcerations 􏰂Infections 􏰂Sub-metatarsal pain

Question 91

Lesions with Digital Deformities 􏰂 Hammertoes PIPJ, distal tip of digit, sub-metatarsal head

Answer 91

􏰂 Clawtoes -PIPJ, DIPJ, distal tip of digit, sub-metatarsal head 􏰂 Mallet Toe -DIPJ, distal tip of digit 􏰂 Adductovarus 􏰂5th – dorsolateral PIPJ, 4th – distolateral digit or in the webspace

Question 92

Digital Deformity Treatments Palliative: Surgical:

Answer 92

Palliative: 􏰂Reduce lesions 􏰂Pad lesions 􏰂Shoe modifications Surgical

Question 93

Forefoot Pain CMINT

Answer 93

􏰂Congenital – TEV, metatarsus adductus, Morton’s foot, Long 1st ray, Plantarflexed 1st ray, 1st metatarsal elevatus, limb length discrepency 􏰂Metabolic – Gout, RA, psoriatic arthritis 􏰂Infectious – Septic joint, cellulitis 􏰂Neoplasms – Soft tissue or bone 􏰂Traumatic – Micro or macro trauma, Iatrogenic (surgery)