Lecture 1 Flashcards
(117 cards)
1
Q
What is included in a PE for FNA exam (foot and ankle)
A
Gait Sensory exam Ankle Alignment Hindfoot Midfoot Forefoot
2
Q
What is included in the imaging for FNA exam?
A
Diabetic issues
Yeah thats what the slides say
3
Q
Stance phase includes:
A
Initial contact Loading response Midstance Terminal stance Pre swing
4
Q
Swing phase includes:
A
Initial swing
Mid swing
Terminal swing
5
Q
What causes a lack of normal push-off?
A
Hallux rigidus
6
Q
What causes the increased external rotation?
A
Ankle arthritis
7
Q
Besides watching them walk, how else should you assess gait?
A
Shoes
- heel and forefoot wear
- heel counter wear
- toe scuffing in foot drop
8
Q
transcutaeous oximetry (PtcO2) <40 mmHg?
A
Impaired wound healing
9
Q
Transcutaneous oximetry (PtcO2) <30 mmHg?
A
Critical ischemia
10
Q
Signs of vascular changes on the FNA exam?
A
Venous stasis
Hair loss
11
Q
What are you checking for with fna palpation?
A
Effusion Synovitis Deformity Crepitus Loose bodies
12
Q
What is equinus contracture
A
Limited ankle dorsiflexion not caused by bony impingement
13
Q
What conditions are implicated with equinus contracture?
A
Plantar fasciitis Metatarsalgia Arch pain Diabetic ulcers Achilles tendinopathy
14
Q
What is silfverskiold test?
A
Assess the isolated gastrocnemis vs the gastrocnemius-soleus contracture
Test knee in full extension and at 90*
15
Q
Silfverskiold test gastroc tightness?
A
Improved ankle dorsiflexion with knee flexion = gastroc tightness
The gastroc is the more superficial calf muscle (soleus is deep) and so bending the knee isolates it and differentiates between the two for exam
16
Q
Alignment deformities?
A
Flexible flatfoot
Flexible toe deformities
Hypermoble 1st ray
17
Q
What is the normal apex of the foot when weight bearing?
A
Normal apex of 1 cm when weight bearing
18
Q
Types of foot apex disorders?
A
Planus - flat foot
Cavus - high arch
Rocker bottom - shit show
19
Q
Causes of planus problems?
A
Idiopathic
Equinus contracture
PTT dysfunction c
20
Q
Causes of cavus problems?
A
Idiopathic
Charcot-marie-tooth
21
Q
Causes of rocker bottom alignment?
A
Charcot
Congenital vertical talus
22
Q
What will looking at a person’s foot from behind while weight-bearing?
A
Too many toes sign
You should see 1-2 toes, if you see more its a valgus hindfoot problem
23
Q
What is the coleman block test?
A
Assess the flexibility fo deformity of varus hindfoot
The block will correct the deformity if it is secondary to plantar flexed first ray
24
Q
What tests are used to ID syndesmotic (high ankle) injuries?
A
Squeeze test (88% specific)
External rotation test
25
What does anterior drawer test assess?
The anterior talofibular ligament (ATFL)
26
How is the anterior drawer test of the ankle performed?
Ankle is at 20* plantar flexion and knee is flexed at 90*
27
What does the talar tilt assess?
Calcaneofibular ligament (CFL) in neurtral position
Anterior talofibular ligament in plantar flexion
28
How is the talar tilt exam performed?
Inversion force to hindfoot
<5* is normal
29
What is the achilles tendon comprised of?
Gastrocnemius tendon
| Soleus tendon
30
Where is the retrocalneal bursa?
It lies between the anterior surface and posterior superior aspect of the calcaneus
31
What does achilles tendon do while running?
It transfers forces of 6-10 times the body weight during running
32
What is tendinosis?
describes chronic degeneration of a tendon that is hypovascular state with an impaired healing process
MC in adults
33
What is tendonitis?
Inflamed Tendon MC in kids
34
What is tendinopathy?
Its what you call things when you dont know what they are
35
Types of achilles tendinopathy?
Non insertional tendinopathy of Achilles tendon (middle of tendon)
Insertional tendinopathy of achilles tendon (at insertion)
36
What is a pump bump?
Prominent process of the calcaneus impinging on the retrocalcaneal bursa and or achilles tendon
37
What is a tell tale sign of retrocalcaneal bursitis?
pain anterior to the Achilles tendon that is increased by squeezing the bursa from side to side and just anterior to the achilles tendon
38
Conservative treatments for posterior heel pain?
Activity modification
Heel lifts and shoe wear modification
PT
50-60% get better with conservative
39
Kagers triangle?
Measure of the achillies tendon in relation to the other soft tissue in medial view of the ankle
Should make a nice triangle
See slide 29 if you want a pic
40
Where is achilles rupture usually found?
5-7cm proximal to the insertion of the tendon into the calcaneus
41
Who is the typical pt who gets achilles rupture?
Middle-aged men who play sports like tennis and b ball
“Weekend warriors”
42
How is achilles rupture described?
Sudden sever calf pain
“Gunshow wound”
“Direct hit from a raquet”
Can resole quickly
43
Why would a achilles rupture be misdiagnosed?
The severe pain can resolve quickly and be misdiagnosed as an ankle sprain
This causes significant weakness and impairs ambulation
44
What will you see on PE with an achilles rupture?
Edema
Difficulty bearing weight
Palpable defect in tendon
Neutral foot position
45
What is a thompson’s test?
Pt is lying prone and knee is at a 90*. Calf is squeezed
Negative: passive plantar flexion of ankle
Positive: absence of plantar flexion
46
What is matles test?
Pt is prone with knees bent at 90*, foot position is compared.
Affected side is more dorsiflexed
47
What is the initial tx for achilles rupture?
Bulky jones posterior ankle splint in equinus (plantar flexion)
Nonweightbearing (crutches)
72hr consult
Monitor for DVT
48
Surgery is the cure all for achilles rupture right?
Nonoperative management has similar outcomes to surgery
49
What is the surgical recover period like for achilles rupture?
4-6 months of rehab with progression of motion and activity
Brief period of Immobilization
Tapered heel lift x several weeks
50
Second achilles rupture?
Second rupture occurs with either type but is more common in nonsurgical treatment
51
What is the primary cause of medial foot/ankle pain in the middle aged patient?
Posterior tibial tendon dysfunction
52
What does the posterior tibial tendon do?
The main supporting structure of the medial ankle and arch along with spring ligament (talo navicular ligament)
53
What are some common causes of posterior tibial tendon dysfunction?
```
Tendon degeneration
Overload (obesity/activity)
Inflammatory condition (RA, AS)
```
54
What happens with Posterior tibial tendon dysfunction?
Tendon thickens and degenerates
It becomes ineffective at supporting the medial longitudinal arch
Pes planus (flatfoot) developes
Foot becomes fixed and non-flexible
55
Describe the classic patient with posterior tibial tendon dysfunction?
Overweight woman older than 55yrs old
56
What is the presentation of posterior tibial tendon dysfunction?
Lateral pain presents as the collapsed flat foot abrupts the fibula causing subfibular impingement in the sinus tarsi
Ankle pain is the presenting symptom (often late stage)
57
Risk factors for posterior tibial tendon dysfunction?
Asymptomatic flexible flatfoot deformity
Previous corticosteroid injections
DM
58
Exam for posterior tibial tendon dysfunction?
Look at both feet from knee down while pt is standing
edema and tenderness posterior and inferior to the medial malleolus along the course of the PTT
Increased hindfoot valgus (too many toes)
Inability to perform single limb heel rise
59
single limb heel rise?
Normal: Pt can perform a toe raise (calf raise) on one leg with the PTT pulling the heel into inversion
PTT: pt cannot perform toe raise with one leg
60
Radiological findings for posterior tibial tendon dysfunction?
AP and Lat shows:
Pes planus
Alignment changes at talonavicular and other joints
61
What should Talo metatarsal angle be?
Meary’s angle
| >4* = pes planus
62
What should calcaneal pitch be?
17-32 degrees = normal
63
Treatments for posterior tibial tendon dysfunction?
Short leg cast/brace x 4 weeks
Then
Ankle-foot orthosis (AFO)
Often surgery is required
64
Surgery for posterior tibial tendon dysfunction?
no rigid flatfoot(mild) : tendon transfer
Rigid flatfoot: stabilization of hindfoot by arthrodesis is best tx
65
If your pt has a medial ankle sprain what do you need to r/o?
Posterior tibial tendon dysfunction
Medial ankle sprain is rare so you need to look elsewhere
66
What structures are in the tarsal tunnel?
Tom, dick and a very nervous harry
```
T: Tibilias posterior
D: flexor digitorum longus
A: artery (posterior tibial)
V: vein (posterior tibial)
N: nerve (tibial)
H: flexor hallucis longus
```
67
What is tarsal tunnel syndrome?
Compression of tibial nerve in fibrous flexor retinaculum
May mimic plantar fasciitis
Differentiated by paresthesias on tinel’s test
68
What is the cause of tarsal tunnel syndrome?
Usually idiopathic
Can be:
- ganglion
- bony lesion
69
Common presentation of tarsal tunnel syndrome?
Diffuse poorly localized pain along medial ankle
Paresthesias/dysthesias (tingling)/(burning) along medial ankle into arch
70
PE for tarsal tunnel?
TTP over tarsal tunnel just posterior to the medial malleolus
Decreased sensation in distribution of the posterior tibial nerve on the plantar aspect of the foot
71
What is tinels sign in relation to tarsal tunnel?
Percussion over the posterior tibial nerve should reproduce the symptoms
72
What foot deformity makes tarsal tunnel syndrome worse?
Pes planus increases the tension on the nerve
73
Diagnostic testing for tarsal tunnel syndrome?
X ray - normal
MRI - normal
Electrodiagnostic test - can ID tibial nerve entrapment
74
Is electrodiagnostic testing accurate for tarsal tunnel?
Not accurate at ankle level and below
Pos or neg test doesnt always correlate w intraoperative findings or clinical outcomes
75
Tx for tarsal tunnel syndrome?
Correct hind foot valgus
- Medial heel wedge
- Orthotic device
NSAID, TCA, B6
PT
Surgery
76
How is tarsal tunnel treated surgically?
Distal tarsal tunnel is released with the lateral and medial plantar nerve branches at the bifurcation deep to the deep abductor hallucis muscle fascia
The tunnel sheath is cut where it crosses the nerves
77
How effective is the surgery for tarsal tunnel syndrome?
Lower success rate when compared to carpal tunnel release
78
You didnt listen and you got the surgery anyway, the symptoms didn’t get better, what are some reasons why?
Surgical nerve release can lead to increased scarring and increased symptoms
79
So we can just try the surgery again right?
Revision tarsal tunnel surgery results are extremely poor especially if you did decompress the nerve the first time
80
Who gets referred?
- Sever or progressive symptoms
- Loss of motor strength
- pain that radiates abovec knee (herniated disk)
- sever pain to light touch (complex regional pain syndrome)
81
Whats going on with plantar fasciitis?
The plantar fascia provides support to the foot and as the toes extend during the stance phase of gait, the plantar fascia is tightened by a windlass mechanism, resulting in elevation of the longitudinal arch, inversion of the hind foot and resultant external rotation of the leg
82
What is the MC cause of heel pain in adults?
Plantar fasciitis
83
Etiology of plantar fasciitis?
Probably:
| A degenerative tear of fascial origin from the calcaneus followed by a tendinosis type reaction
84
What foot type gets plantar fasciitis?
It is not associated with a particular foot type
85
Histologic findings of plantar fasciitis?
Chronic degenerative changes in the fibers of the plantar fascia
86
Describe the pain of plantar fasciitis
Most intense in morning
Better: sitting
Worse: standing/walking
Insidious onset
87
PE for plantar fasciitis?
TTP directly over plantar medial calcanea tuberosity and 1-2 cm
distally along the plantar fascia
Must be in wt bearing to reproduce
Tight achilles tendon
Passive dorsiflexion causes pain
88
What is baxters nerve pain?
Mimics plantar fascia pain
Found more medial than plantar fasciitis over the abductor hallucis
89
Where is the baxter’s nerve?
1st branch of the lateral plantar nerve
Just superior to the plantar fascia insertion between abductor hallicus and quadratus plantae
90
What do bone spurs and plantar fasciitis have in common?
Osteophytes (bone spurs) and plantar fasciitis are often associated.
50% of pts will get them under the flexor digitorum brevis muscle just superior to the plantar fascia
91
What are the treatment options for plantar fasciitis?
PT (stretching)
Activity modification
Surgery
Steroids
92
What is the best treatment for plantar fasciitis?
Doesn’t matter, 90-95% improve w/in one year, regardless of tx
(Takes 6-12 mo though)
93
What is the surgical option for plantar fasciitis?
Partial release of the plantar fascia
DO NOT ATTEMPT UNTIL AFTER 6 MONTHS OF NONSURGICAL TX
94
What are some adverse outcomes of therapy for plantar fasciitis?
Corticosteroids
- Fat pad necrosis
- Rupture of plantar fascia
Surgery
- may not work
- can cause complete disruption of tendon
95
When to refer plantar fasciitis pts?
Symptoms dont respond to tx
Need surgical release
You think radial or focal shock wave tx may help
96
MC soft-tissue tumors in foot and ankle? (2)
Ganglia
| Plantar fibromas
97
How common are foot tumors that are malignant?
Very rare
98
Describe a typical ganglia of foot or ankle
Small 2-3cm masses that arise on top of side of foot
- commonly on the lateral aspect of the foot or ankle
- arising from subtalar or ankle joint
99
What are plantar fibromas?
Benign thickening of the plantar fascia varying in size 1-6cm
Similar to dupuytrens disease but usually dont cause deformities
100
Differentiating ganglion cyst from plantar fibroma
Ganglion cyst: Movable mass
Plantar fibroma: focal or multiple discrete masses that are hard (rubbery) and attached to fascial band
101
Diagnostic tests for masses?
Radiographs usually enough
Aspiration (ganglion)
Usually don need more
102
Treatments for ganglion cyst?
Pierce 3-4 times w needle
If it comes back, excise it
Corticosteroid injection has not been proven effective
103
Treatment for plantar fibroma?
Shoe mods to cushion and float the fibroma
Surgery if its bad or grows a lot
104
When to refer soft tissue masses?
If you cant tell what it is
If you stick it w a needle and it comes back
105
What is metatarsalgia?
Pain under the heads of the metatarsals
Secondary to metatarsal length or alteration of weight distribution
106
What conditions are associated with metatarsalgia?
Claw and hammer toes
107
Presentation of metatarsalgia?
Activity related pain localized to plantar aspect of forefoot over metatarsal heads
Diffuse callous formation
“Walking on pebbles”
108
What to examine during PE for metatarsalgia?
Alignment of toes
Edema, ROM, stability of
MTP joints
Masses
Calluses
109
What radiographs should be ordered for metatarsalgia?
Wt bearing AP and lateral are used to assess alignment
110
Treatment for metatarsalgia?
Shoe mods: low heal, well cushioned w large toe box
Metatarsal pads that redistribute weight
Shave callus
Surgery to realign metatarsal head
111
What is morton’s neuroma?
Compressive neuropathy of interdigital nerve
Usually between 3rd and 4th metatarsals
112
Clinical presentation of morton’s neuroma?
Pain and burning on plantar aspect of web space
Pain radiating distally to toe
Exacerbated by narrow or high heeled shoes
113
What is a mulder click?
An audible click produced by squeezing two metatarsal heads together while putting pressure on the interdigital space w other hand
114
What is mulder’s sign?
squeezing two metatarsal heads together while putting pressure on the interdigital space w other hand
Produces mulder click and pain (morton’s neuroma symptoms are reproduced)
115
Radiological findings with morton’s neurmoa?
Radiographs ar normal
MRI shows inflammation of the nerve
MRI is not required for diagnosis
116
Tx for morton’s neuroma?
Shoe mods: low heal, well cushioned w large toe box
Metatarsal pads that redistribute weight
Steroid injection
Excision of the neuroma
(Basically the same as metatarsalgia)
117
Beginning of History?
History began on July 4 1776.
Everything before that was a mistake
- ron swanson
