LE Part 2 Flashcards
(179 cards)
1
Q
How do we decide when to get a knee x-ray?
A
Ottawa knee rules
2
Q
What are the ottawa knee rules?
A
- Radiograph if 1 criterion is met
- Age >55
- Tenderness at head of fibula
- Isolated tenderness of the patella
- Inability to flex knee to 90 degrees
- Inability to bear weight for 4 steps both immediately after the injury and in ED
3
Q
Knee anatomy: Ligaments and menisci
A
4
Q
What are the borders of the knee joint capsule?
A
- Superiorly: femur at margin of condyle
- Posteriorly: encloses condyles and intercondylar fossa
- Inferiorly: margin of tibial plateau except where tendon of popliteus crosses the bone
- Anteriorly: quadriceps tendon, patella, and patellar ligament continuous with medial and lateral margins
5
Q
Knee disorders/injuries
A
- Ligamentous injuries
- Meniscal injuries
- Knee dislocations
6
Q
What is the function of the ACL
A
- Primary stabilizer of the knee
- Prevents anterior translation of tibia in relation to femur
7
Q
MOI of ACL tear
A
- Sudden deceleration with rotational trauma or hyperextension force applied to knee
8
Q
Pathology of ACL tear
A
- Complete rupture of ligament most often occurs
- Commonly associated with a meniscal tear: MCL, LCL, or PCL rarely damaged
9
Q
Presentation of ACL tear
A
- Twisting or hyperextension injury followed by sudden pain and giving way of the knee
- Audible pop
- Joint effusion within first few hours –> increased pain
10
Q
Physical exam of ACL tear
A
- Joint effusion
- Limited ROM –> inability to bear full weight
- +Lachman test (most reliable)
- Anterior drawer test
- pivot shift test (only done when sedated)
11
Q
Diagnostics of ACL tear
A
- X-ray knee series
- AP, lateral, and tunnel views
- Most often only shows effusion
- May show avulsion fracture of the lateral capsular margin of the tibia –> Segond fracture
- Tibial eminence fracture common in patients with open growth plates (avulsion)
- MRI often ordered to confirm diagnosis
12
Q
How does a joint effusion appear on knee imaging?
A
Well-defined rounded homogenous soft tissue density within the suprapatellar recess on a lateral radiograph
13
Q
Management of ACL tear
A
Initial
* RICE with knee immobilizer brace +/- crutches
* Pain relief –> acetaminophen before NSAIDs
* Consider aspiration if effusion large
* Start early ROM exercises as pain allows
Refer to ortho
* Young patients –> reconstruction with graft from patients patellar, hamstring, or quad tendon or cadaver
* Older patients –> PT to strengthen surrounding muscles to improve stability
14
Q
What is the function of the PCL?
A
Prevents posterior translation of the tibia in relation to the femur
15
Q
MOI of PCL tear
A
- Direct blow to the tibia ie knee strikes dashboard in MVA or fall onto knee
- Extreme hyperextension (associated ACL rupture)
16
Q
Pathology of PCL tear
A
- Ranges from stretch injury to complete rupture
- Often associated with other injuries: collateral ligaments, ACL ruptures
17
Q
Physical exam for PCL tear
A
- posterior drawer test
- Assess NV status if multiligamentous injury suspected –> assess with ABI if <.9 order arterial imaging to r/o intimal tear that could lead to thrombosis
18
Q
Clinical presentation of PCL tear
A
- Sudden pain and giving way of knee
- Joint effusion within first few hours –> increased pain
19
Q
Diagnostics for PCL tear
A
- Same as ACL
- X-ray knee series: AP, lateral, and tunnel views
- Often shows effusion
- May show avulsion fracture
- Tibial eminence fracture in patients with open growth plates
- MRI to confirm
20
Q
Management of PCL tear
A
Initial
* RICE
* Knee immobilizer
* Begin ROM after 1-5 days
* Isolated PCL injuries: PT to strengthen quads and hamstrings and restore ROM and if PT fails to restore stability, reconstruction
* Multi-ligamentous injuries: reconstruction
21
Q
Sequelae of PCL tear
A
Osteoarthritis
22
Q
What is the function of collateral ligaments?
A
Provide stability from varus (LCL) and valgus (MCL) stress
23
Q
MOI of collateral ligament tear
A
- Medial collateral ligament (MCL): lateral (valgus) blow to the knee
- Lateral collateral ligament (LCL): usually in association with other traumatic knee injuries
24
Q
Presentation of collateral ligament tear
A
- Localized pain
- Tenderness
- Swelling and stiffness along ligament course
- Worsens over 6-8 hours
- Patient may be able to bear weight after injury
- 1-2 days after injury ecchymosis along ligament course and small effusion
25
Physical exam of collateral ligament tear
* Assess uninjured extremity first to gage normal laxity
* Varus/valgus testing performed in extension and 30 degree flexion
* Laxity noted in extension - more significant trauma
* Instability may be masked by pain and involuntary muscle contraction
26
Diagnostics of collateral ligament tear
* AP/lateral knee x-ray: assess for avulsion fracture
* MRI to confirm
27
Management of collateral ligament tear
Sprains-partial tear (grade I and II)
* RICE, hinged knee brace, NSAIDs
* Early ROM exercises
* Crutches with weight bearing as tolerated
Complete rupture
* Refer to ortho
* Tx varies based upon location of rupture
* Conservative vs. repair or reconstruction
28
Function of meniscus
* Gel like pads that sit between femur and tibia
* Function as shock absorbers and provide smooth gliding surface during ambulation
29
MOI of meniscal injury
* Rotational force of the knee while foot is planted
* Older patients (degenerative tear): minimal (squatting down) to no trauma
30
Presentation of mensical injury
* Pain and stiffness following MOI that progressively worsens over 2-3 days
* Ambulation after injury is possible
* Patient may report hearing a pop at time of injury
* + locking, catching, or popping noted more after effusion begins to resolve
* Tenderness along joint line of affected meniscus with medial meniscus more commonly affected
* Effusion (directly affects ROM): larger in more lateral tears, smaller with tears of avascular central body
* +McMurray - painful click noted on exam
31
Diagnostics of meniscal injury
* XRay: 2 view knee series to r/o other pathologies
* Add a weight bearing AP with knee in 45 degree flexion if >40 y/o to provide info on amount of osteoarthritis
* MRI knee to identify details of tear
32
Management of meniscal injury
Initial: RICE, NSAIDs
Referral to ortho for arthroscopic repair if indicated
* If no indications for surgery, initial management then PT
33
Indications for referral to ortho for arthroscopic repair of meniscal injury
* Young patients with traumatic tear
* Failure to conservative therapy
* Mechanical symptoms
* Evidence of ligamentous instability
34
Epidemiology of knee dislocation
MC in young males
35
MOI of knee dislocation
* Severe ligamentous disruption
* MVA
* Fall from heights, trampoline falls
* Martial arts
* Spontaneous with walking in morbidly obese patients
36
How is knee dislocation characterized?
* Direction of tibia relative to femur
* Anterior
* Posterior
* Lateral
* Medial
37
Presentation of knee dislocation
* Obvious deformity with severe pain and limited ROM
* 50% spontaneously reduce: inquire about mechanism and position of leg following injury and suspect if grossly unstable on exam
* Ecchymosis and swelling often present
* Can have popliteal artery, common peroneal and tibial nerve injuries; limb-threatening vascular injuries even with normal pulses
* Attempt ligamentous assessment: may be limited due to large effusions; hyperextension >30 degrees when leg is lifted by the foot indicates gross instability
38
Diagnostics of knee dislocation
* XR 2 view knee: initial assessment and post reduction
* CT to assess for occult fracture after reduction and stabilization
* MRI to assess soft tissue after reduction and stabilization and assess extent of internal derangement
39
Management of knee dislocation
* Reduction
* Ortho and vascular surgery consultation
* Admit for serial NV checks
40
How is reduction of knee dislocation performed?
* Procedural sedation
* Immediate reduction by longitudinal traction
* Followed by post-reduction NV check
* If distal pulses intact, assess vascular integrity by ABI or angiography
* Immobilize knee in 20 degree flexion and allow access to distal feet for serial NV assessment
* Post reduction imaging
41
Compartments of the lower leg
42
Bones of the lower leg
43
What imaging can be performed for tibia/fibula?
Tib/fib series:
* AP
* Lateral
44
Disorders of the tibia and fibula
Tibia and fibula fractures
45
MOI of tibial plateau fracture
* Valgus stress = lateral plateau fracture due to high-energy trauma in young patient
* Low-energy trauma in osteoporotic geriatric patient during twisting or fall
46
Presentation of tibial plateau fracture
* Sudden onset of pain after trauma with inability to bear weight
* Swelling, joing effusion
* +/- deformity
* Limited ROM
47
Diagnostics for tibial plateau fractures
* XR: AP and lateral knee; oblique views: beneficial if AP/lateral are inconclusive
* CT/MRI: evaluate amount of displacement prior to surgical repair; assess for soft tissue injury
* CTA: if vascular compromise
48
What can be present on lateral x-ray for tibial plateau fracture?
Lipohemarthrosis
49
Initial managmeent of tibial plateau fracture
* Compression
* Ice
* Analgesics
* Splinting in extension
50
When would you get emergent consultation for tibial plateau fracture
* Open fracture
* NV compromise
* Compartment syndrome
51
When would you get urgent consultation for tibial plateau fracture
* Fractures with any displacement or depression
* Most all will require ORIF
* Consult within 24-48 hours
52
Treatment of non-displaced tibial plateau fracture
* Long-leg posterior splint or knee immobilizer
* Crutches
* Strict non-weight bearing
* F/u with ortho within 1 week
53
MOI of tibial tubercle fracture
* Sudden force to the flexed knee with quadriceps contracted
* Ex: knee flexion at the beginning of a jump or an awkward landing
54
Presentation of tibial tubercle fracture
* MC in children and bones with open grwoth plates
* Pain, tenderness, and swelling over tibial tuberosity
* Displacement of patella
* Loss of ROM
55
Diagnostics for tibial tubercle fracture
XR knee- 2 view
56
Management of tibial tubercle fracture
Incomplete or small avulsion
* RICE
* Knee immobilizer, long leg posterior splint, no weight bearing
* Refer to ortho within 1 week
Complete avulsion
* RICE
* knee immobilizer, long leg posterior splint, no weight bearing
* Urgent ortho consult for ORIF (24-48 hrs)
57
What is the MC long bone frature
Tibial shaft fracture most often in association with fibular fracture
58
MOI of tibial shaft fracture
* Adults: high-energy direct blow to the tibia
* Children: twisting injury
59
presentation of tibial shaft fracture
inability to bear weight
pain, swelling
deformity
60
what complications should be assessed for in tibial shaft fracute
open fracture
nv compromise
compartment syndrome
61
diagnostics of tibial shaft fracture
AP and lateral tibia/fibula xray, add on knee and ankle if associated injury suspected
add oblique xray or CT to further evaluate complexity of fracture
bone scan if occult fracture is suspected
62
initial management of tibial shaft fracture
RICE
analgesics
long leg posterior splint
63
what conditions require emergent consultation in tibial shaft fracture
open fracture
tib/fib fracture
nv compromise
compartment syndrome
64
management of displaced tibial shaft fracture
closed reduction and long leg splinting (posterio +stirrup)
admit for observation and monitoring of complications
consult ortho
65
management of non-displaced tibial shaft fracture
long-leg posterior splint
crutches
strict non-weigth bearing
f/u with ortho within 1 week
66
what is a stirrup splint indicated for
ankle sprains
isolated fractures of the fibula or tibia
reduced ankle dislocations
67
position of foot for stirrup splint
ankle in 90 degree dorsiflexion, patient in prone position to prevent shortening the achilles
68
is fibula fracture often isolated?
no often associated with tibia fracture
69
moi of fibula fracture
direct blow to the lower leg
rotational force
70
clinical presentation of fibula fracture
may be able to bear weight if isolated
point tenderness and localized pain with swelling
defomity if fraction is displaced
assess for maisonneuve fracture
71
what is a maisonneuve fracture
proximal fibula fracture with associated medial malleolus fracture or ligament disruption of the ankle without fracture
72
diagnostics of fibula fracture
2 view tib/fib
isolated knee/ankle if needed
73
initial management of fibula fracture
RICE
analgesics
long leg posterior splint
74
when would emergent consultation be needed for fibula fracture
open fracture
tib/fib fracture
nv compromise
crush injuries
compartment syndrome
75
management of displaced or maisonneuve fracture
posterior long leg splint
refer to ortho within 24-48 hours
76
management of fibular head/neck fracture
knee immbolizer splint or long leg posterior
ortho consult within a wekk
77
management of distal fibula fracture
stirrup splint or air case splint
ortho within a week
78
look back at anatomy and such of the foot and ankle
79
what should be noted on anterior view, standing and supine inspection and palpation of foot and ankle
alignment of the toes, position of the foot in relation to the limb and medial curvature of the forefoot
palpate plantar fascia, MTP joints, and head of metatarsal for sesamoid bone tenderness
80
posterior view of foot and ankle inspection and palpation
heel alignment while standing- normal is neutral or slight valgus with no more than one or two lateral toes visible from behind
palpate achilles tendon insertion
81
medial view of foot and ankle inspection and palpation
arch should be symmetric, high arch = pes cavus, flatfoot = pes planus
prominence of the medial midfoot = accessory navicular bone
palpate for perimalleolar tenderness
82
lateral view of foot and ankle inspection and palpation
inspect while standing for calluses, ankle swelling or prominence of the posterior calaneus
palpate for perimalleolar tenderness
83
inspection and palpation of foot and ankle while standing on toes
note symmetry
heels should move into a normal-slight varus postiion
84
gait observing ankle and foot
analyze alignment of foot during different phases of gait: heel strike, mid stance, toe-off, swing phase
look for obvious limp, lurch, dragging of the feet, in-toeing out-toeing, and drop-foot gait
85
normal range of motion of foot and ankle
starting position: foot perpendicular to tibia
plantar flexion: 0-50 degrees
dorsiflexion: 0-20 degrees
inversion: 0-35 degrees
eversion: 0-25 degrees
flexion of toes 0-30 degrees
extension of toes: 0-80 degrees
86
muscle testing of posterior tibialis
resist as patient inverts and plantar flexes
87
muscle testing of anterior tibialis
resist as patient inverts and dorsiflexes the foot
88
muscle testing of peroneus longus and brevis
resist eversion
89
muscle testing of extensor hallucis longus
resist dorsiflexion of the great toe
90
muscle testing of flexor hallucis longus
resist plantar flexion of the great toe
91
anterior drawer test of the foot
excessive anterior translocation of the foot is indicative of anterior talofibular ligament instability
92
talar tilt test
test integrity of the calcaneofibular ligament, deltoid ligament, anterior and posterior talofibular ligaments
calcaneofibular: inversion from anatomical position
deltoid: eversion from anatomical position
anterior talofibular: plantarflexion and inversion
posterior talofibular: dorsiflexion with inversion and eversion
93
thompson's test
compression of the calf in a prone position should produce plantar flexion
absence of this finding indicates achilles tendon rupture
94
imaging of the ankle
AP
lateral
mortise: better view of ankle joint
95
ottawa ankle rules
radiograph if 1 is present
pain at malleoli
inability to bear weight 4 steps
tenderness posteriorly or inferiorly at the malleoli
96
imaging of the foot
AP
oblique
lateral
97
ottawa foot rules
radiograph if 1 is present
inability to bear weight for 4 steps
tenderness at base of 5th metatarsal
tenderness over navicular bone
98
achilles tendon rupture
occurs 5-7 cm from insertion site on calcaneus
MOI = direct blow or indirect forced dorsiflexion in stop and go sports
99
achilles tendon tear
occurs at insertion site
moi indirect forced dorsiflexion
100
presentation of achilles tendon rupture
often pop sound with sudden severe pain
difficulty bearing weight
palpable defect
weak active plantar flexion
+ thompson test
101
presentation of achilles tendon tear
less acute/severe pain
localized tenderness over insertion site
no palpable defect
102
diagnostics for achilles tendon injury
ankle x-ray: rule out avulsion fracture or other injury
MRI or US confirms dx
103
management of achilles tendon rupture
RICE
short leg posterior splint in slight plantar flexion
non weight bearing
surgical vs non-surgical management depending on comorbidities and goals
follow up with ortho in 1 week
104
management of achilles tendon tear
controlled ankle motion )CAM) boot and PT
follow up with ortho in 1 week
105
moi of achilles tendonitis
microtrauma from reptetitive stress
patient increased training program or rigor for a long period of time
106
presentation of achilles tendonitis
burning pain and stiffness 2-6 cm above posterior calcaneus worse with activity and relieved with rest
- thompson test
no defect noted
ROM and MS normal
long-standing tendonitis may result in palpable calcaneal spur
107
diagnostics for achilles tendonitis
clinical
108
management of achilles tendonitis
Rest, ice, NSAIDs x 7-10 days
chronic tendonitis or no improvement with conservative therapy: refer to PT
109
classifications of ankle sprain
lateral ankle sprain (MC)
medial ankle sprain
high ankle sprain
110
what is a lateral ankle sprain
inversion injury
damage to anterior talofibular ligament or calcaneofibular ligament
111
what is a medial ankle sprain
eversion injiry
damage to deltoid ligament
112
what is a high ankle sprain
severe inversion
damage to the tibiofubular syndesmosis
113
presentation of ankle sprain
history of fall or twisting injury
pain, swelling
ecchymosis
difficulty ambulating
localized point tenderness over involved ligament: assess both malleoli and 5th metatarsal base
decreased ROM
+ Squeeze test if damage to tibiofibular syndesmosis
+ talar tilt with pain with individualized tendon maneuver, instability with grade 3 sprains
+ anterior drawer with anterior talofibular injury
114
what is squeeze test
squeeze tibia and fibula and mid calf
if pain over distal tib/fib, damage to tibiofibular syndesmosis
115
diagnostics for ankle sprain
ankle series if ottawa ankle rules apply
normal unless high ankle sprain: tibiofibular syndesmosis widening
116
management in phase 1 of ankle sprain
rice with nsaids
aircase splint or ankle brace (rarely a cast for high grade injuries)
weigth bearing as tolerated - crutches if severe pain
117
management of phase 2 of ankle sprain
initiate once weight bearing without pain (appx 2-4 weeks after injury)
continue splint
start strengthening exercises and achilles stretching ie writing ABCs, ROM with elastic band, heel raise
118
management of phase 3 of ankle sprain
start once full ROM has returned and strength up to 80% of normal approx4-6 weeks after injury
wean ankle bracing
increased strength exercise intensity: one leg balance, running figure eights
refer to PT if limited ROM and pain after 2-3 weeks of home therapy
119
indications for referral to ortho for ankle sprain
nerve injury
hx of chronic instability
failure to improve after 6 weeks
120
classification of ankle fracture
unilateral fracture without ligament disruption (stable)
bimaleolar (unstable): both medial and lateral malleoli fractured, unilateral malleoli with ligament disruption
trimaleolar (unstable): both malleoli with posterior lip of tibia, both malleoli with ligament disruption
121
MOI of ankle fracture
twisting or fall
inversion: lateral joint
eversion: medial joint
122
presentation of ankle fracture
pain and swelling
point tenderness and limited ROM
identify if point tenderness is only over the malleoli or if ligaments are affected
palpate proximal fibula for tenderness (maisonneuve fx)
assess NV status
123
diagnostics of ankle fracture
ankle xr series: add tib/fib or foot if indicated based upon exam
ct ankle: to evaluate complex fractures prior to surgical repair
124
when would emergent ortho evaluation be indicated for ankle fracture
open fracture
nv compromise
associated dislocation
unstable and displaced - ORIF
125
management of unstable, nondisplaced ankle fracture
short or long leg splint/cast; non weight bearing
f/u with ortho within 7 days
126
management of stable ankle fracture
weight-bearing splint/cast x4-6 weeks
127
management of suspected occult fracture
short leg splint and repeat x-ray in 10-14 days
repeat x-ray in 10-14 days will reveal a bony callus around occult fracture as healing begins
128
what is the mc tarsal bone fracture
calcaneal fracture
129
moi of calcaneal fracture
axial loading, often associated with vertebral fracturec
130
clinical presentation of calcaneal fracture and talar fracture
severe pain in heel with inability to bear weight
swelling, ecchymosis, and deformity may be present
assess NV status, cap refill preferred or doppler, distal pulses may be diminished due to swelling
assess lumbar spine for tenderness
131
diagnostics for calcaneal fractures
xray: foot and ankle series
lumbar x-ray if + exam
ct scan ankle/foot for further evaluation of fracture may be needed for surgical planning
132
management of calcaneal/talar fractures
RICE
well padded posterior short leg splint
non-weight bearing
ortho consult within 24 hours: displaced fractures require ORIF, non-displaced fractures may be treated conservatively with serial x-rays to ensure displacement doesn't occur
133
what is the 2nd MC tarsal fracture
talar fracture
134
anatomic considerations for talar fracture
extensive blood supply
at risk for avascular necrosis
135
moi of talar fracture
high force plantarflexion, dorsiflexion or inversion force
136
diagnostics for talar fracture
foot and ankle series
CT scan ankle/foot for further evaluation of fracture if surgery is considered
137
what is ankle dislocation
displacement of talus from the tibia
138
types of ankle dislocation
posterior (MC)
lateral
139
moi of posterior ankle dislocation
posterior force on a plantar flexed foot
140
moi of lateral ankle dislocation
forced inversion, eversion, or external or internal rotation of the ankle
141
ankle dislocations are highly _____
unstable. disruption of the lateral or medial ligaments and/or tibiofibular syndesmosis
142
clinical presentation of ankle dislocation
grossly deformed
posterior dislocation: locked in plantar flexion with the anterior tibia easily palpable
assess nv status: if vascular compromise noted, reduction not delayed for imaging
143
diagnostics of ankle dislocation
ankle/foot series
CT/MRI often needed to further assess associated fx or ligamentous damage
144
management of ankle dislocation
reduction via procedural sedation, grasping heel and foot and downward traction and applying posterior leg splint
reassess NV status
obtain post reduction films
consult ortho immediately for repair of capsular or ligamentous tears
145
moi of metatarsal fracture
twisting or rotational force
blunt trauma
146
clinical presentation of metatarsal fracture
pain with weight bearing
swelling, ecchymosis, and tenderness over the fracture site
in stress fractures, may only demonstrate tenderness on exam
fracture at base of 5th metatarsal = Jones fracture
147
diagnostics for metatarsal fracture
foot series: stress fracture may not be evident in early presentation, repeat in 2-3 weeks
consider CT or bone scan if still normal and a suspicion of stress fracture exists
148
management of metatarsal fracture
single nondisplaced metatarsal neck and shaft fracture placed in short leg posterior cast or fracture brace to immobilize the fracture, weight-bearing is permitted as tolerated
Multiple metatarsal fractures or displaced/angulated fractures: consult ortho for open or closed reduction
149
what is tarsometatarsal injury
AKA: lisfranc joint
disruption of the tarsometatarsal joint often associated with fx of the metatarsals and tarsalts
150
MOI of tarsometatarsal injury
axial load placed on plantar-flexed foot followed by forcible rotation, bending or compression
Ex: crush injuries, high-impact accidents such as MVA, or high-impact sports
151
clinical presentation of tarsometatarsal injury
midfoot pain/tenderness
inability to bear weight
+ deformity, swelling, ecchymosis
assess for compartment syndrome and NV injury
152
diagnostics for tarsometatarsal injury
weight bearing foot series, often bilateral images for comparison
CT/MRI if clinical suspcion but normal x-rays
153
management of non0displaced tarsometatarsal injury
non-weight bearing splint/cast (short-leg posterior) x 6-8 weeks
then rigid arch support x 3 months
154
management of displaced fracture/tmt joint
splint with non-weight bearing short-leg posterior splint
refer to ortho for ORIF
155
what is the most common fracture
5th phalanx
156
what is the most common dislocation of the phalanges
MTP of 1st joint
157
clinical presentation
pain/tenderness
swelling
ecchymosis
deformity
limited ROM
158
diagnostics for phalangeal injury
foot series
159
management of non-displaced phalangeal injury
buddy tape
160
managemnt of displaced/angulated phalangeal injury
reduce under local anesthesia and buddy tape
161
management of dislocation of phalnge
digital block with traction reduction and repeat post reduction films
162
what is hallux valgus
lateral deviation of the great toe at the metatarsophalangeal joint
163
who more commonly gets hallux valgus
10x more common in females
caused by tight fitting shoes and osteoarthritis
164
clinical presentation of hallux valgus
pain and swelling of the 1st MTP joint aggravated by shoe wear
most patients have normal ROM
165
diagnostics for hallux valgus
foot series
measure valgus angulation at the MTP joint: normal is <15 degrees
166
non-surgical management of hallux valgus
patient education and shoe wear modifications
recommend shoes with adequate width at the forefoot, soft material and stitiching patterns over the bunion
avoid high heels
usually successful in mild to moderate cases
refer to ortho for surgical evaluation patients who remain symptomatic despite conservative therapy
167
what is morton's neuroma
perineural fibrosis of the common digital nerve as it passes between the metatarsal heads
most commonly at base of the 3rd and 4th toes
3rd web space
168
who most commonly gets morton's neuroma
5x more common in females
likely related to compression by tight shoes
169
presentation of morton's neuroma
plantar pain in the forefoot MC
burning in nature
aggravated by activity, wearing high heeled or tight shoes
relief with rest
dysesthesias into the affected two toes
many patients state they feel as though they are walking on a marble or there is a wrinkle in their sock
interdigital neuroma test +
170
what is interdigital neuroma test
apply direct plantar pressure to the interspace with one hand and then squeeze the metatarsalts together with the other hand
+ if increased tenderness and pain radiating into the toes
171
diagnosis of morton's neuroma
clinical diagnosis
x-rays normal
MRI and US can detect neuroma but findings are inconsistent
172
management of morton's neuroma
most cases non-surgically managed
patient education: wear low-heeled, well-cushioned shoes with wide toe box, application of metatarsal pad in sole of shoe
corticosteroid injection if unresponsive to conservative therapy
surgical intervention if symptoms persist or recur: surgical excision of the neuroma or division of the transverse metatarsal ligament
173
what is one of the most common causes of heel pain in adults
plantar fasciitis
174
peak incidence of plantar fasciitis
40-60 yo
175
risk factors for plantar fasciitis
obesity
flat feet
prolonged standing/jumping
176
plantar fasciitis clinical presentation
insidious onset
heel pain worse when initiating waljing
typically most severe during 1st steps in morning
pain lessens with walking
worsens toward end of day due to prolonged weight bearing and relieved by sitting
tenderness directly over the medial calcaneal tuberosity and 1 to 2 cm along plantar fascia
passive dorsiflexion of toes may cause increased pain
177
diagnosis of plantar fasciitis
x-rays may be used to rule out other conditions
178
management of plantar fasciitis
non-surgical management for most patients
initial treatment: OTC orthotic heel pad and a home stretching program
avoid barefoot walking and flat shoes
avoid activities that may be causative (dancing, running)
Ic and NSAIDs may be helpful
may take 6-12 months of treatment to resolve
179
management of plantar fasciitis if unresponsive to conservative therapy
corticosteroid into the heel
custom orthotic
surgical treatment with partial release of plantar fascia
