Lower Extremity Disorders part 2 Flashcards
(110 cards)
1
Q
How do we decide when to order a knee x-ray?
A
Ottawa Knee Rules: Radiograph if 1 criterion is met
- Patient age > 55 years
- Tenderness at the head of the fibula
- Isolated tenderness of the patella
- Inability to flex knee to 90 º
- Inability to bear weight for 4 steps both immediately after the injury and in the ED
2
Q
a primary stabilizer of the knee preventing anterior translation of the tibia in relation to the femur
A
ACL
3
Q
MOI of ACL tear
A
Sudden deceleration with rotational trauma or hyperextension force applied to the knee
4
Q
-
Twisting or hyperextension injury followed by:
- Sudden pain & giving way of the knee
- Audible “pop” - Joint effusion within first few hours → increased pain
- Joint effusion
- Limited ROM → unable to bear full weight
- (+) Lachman, Anterior drawer, pivot shift tests
dx?
w/u and findings?
what imaging is often ordered to confirm dx?
A
- ACL tear
- XR Knee series - effusions, avulsion fracture of lateral capsular margin of tibia (Segond fracture), Tibial eminence fracture common in open growth plates
- MRI to confirm
4
Q
pathology of ACL tear
A
- Complete rupture of ligament most often occurs
- Commonly associated with a meniscal tear - MCL, LCL, or PCL are rarely damaged
5
Q
management for ACL tear
A
- Initial
- RICE with knee immobilizer brace, +/- crutches
- acetaminophen before NSAIDs
- aspiration if large effusion
- Start early ROM exercises as pain allows - Refer to ortho
- Young → reconstruction with graft
- Older - PT to strengthen surrounding muscles to improve stability
6
Q
for ACL reconstruction with graft in young patients, the graft is taken from patients ___, ___, or ___ from a cadaver
A
patellar, hamstring, or quadriceps tendon
7
Q
Sequelae of conservative management for ACL tear (2)
A
Medial meniscus tear, secondary degenerative joint disease
8
Q
what ligament prevents posterior translation of the tibia in relation to the femur
A
PCL
9
Q
MOI of PCL tear (2)
A
- Direct blow to the tibia - Knee strikes dashboard in MVA or fall onto knee
- Extreme hyperextension (associated ACL rupture)
10
Q
2 pathologies of PCL tears
A
- Injuries range from a stretch injury to a complete rupture
- Often associated with other injuries - Collateral ligaments, ACL ruptures
11
Q
- Same as ACL (minus special tests unless ACL is ruptured as well)
- (+) Posterior drawer test
- Assess NV status if multiligamentous injury is suspected
- Assess with ABI - if < 0.9 order arterial imaging to r/o intimal tear that could lead to thrombosis
dx?
w/u?
mgmt?
A
- PCL tear
- same as ACL
-
RICE, Knee immobilizer; Begin ROM after 1-5 days
- isolated PCL injuries - PT; reconstruction if PT fails
- multiligamentous injuries - reconstruction
12
Q
possible complication of PCL tear
A
Osteoarthritis
13
Q
what ligaments provide stability from varus and valgus stress
A
collateral ligaments
14
Q
MOI of collateral ligament tear
A
- Medial Collateral Ligament (MCL) - lateral (valgus) blow to the knee; Football clipping injury
- Lateral Collateral Ligament (LCL) - associated with other traumatic knee injuries; Much less common
15
Q
- Localized pain, tenderness, swelling and stiffness along ligament course - Worsens over 6-8 hours
- may be able to bear weight after injury
- 1-2 days after injury ecchymosis noted along ligament course and a small effusion
- Assess uninjured extremity first to gage normal laxity
-
Varus/valgus testing performed in extension and 30° flexion
- Laxity noted in extension = more significant trauma
- Instability may be masked by pain and involuntary muscle contraction
dx?
w/u?
A
- collateral ligament tear
- XR AP/Lat Knee; MRI to confirm
16
Q
mgmt for collateral ligament tear grade I and II
A
Sprains-partial tear (Grade I and II)
- RICE, hinged knee brace, NSAIDs
- Early ROM exercises
- Crutches with weight-bearing as tolerated
17
Q
mgmt for collateral ligament tear Grade III
A
Complete rupture (Grade III)
- Refer to ortho
- Tx varies based upon location of rupture - Conservative (hinged knee brace) vs. repair or reconstruction
18
Q
gel-like pads that sit between the femur and tibia
Function as shock absorbers and provides a smooth gliding surface during ambulation
A
Menisci
19
Q
MOI of meniscal injury (2)
A
- Rotational force of the knee while foot is planted
- Older patients (degenerative tear) - Minimal (squatting down) to no trauma
20
Q
-
Pain and stiffness following MOI that progressively worsens over 2-3 days
- Ambulation after injury is possible
- may report hearing a “pop” - (+) Locking, catching, or popping noted more after effusion begins to resolve
- Tenderness along joint line of the affected meniscus - Medial meniscus MC affected
- Effusion (directly affects ROM)
- Larger effusion MC in lateral tears (closer to joint capsule)
- Small effusion seen with tears of avascular central body - (+) McMurray - painful click noted on exam
dx?
w/u?
A
- meniscal injury
- XR; MRI knee
21
Q
meniscal injury - Add a weight bearing AP with knee in 45° flexion if pt is how old?
A
> 40 y/o
Provides info on amount of osteoarthritis which directly affects surgical outcomes
22
Q
mgmt for meniscal injury?
A
- initial - RICE, NSAIDS
- arthroscopic repair if indicate
- No indications for surgery → initial management then PT
23
Q
Indications for referral to ortho for arthroscopic repair
A
- Young patients with traumatic tear
- Failure to conservative therapy (persistent joint line tenderness)
- Mechanical symptoms
- Evidence of ligamentous instability
24
MOI of knee dislocation
**severe ligamentous disruption**
1. MVA
1. Fall from height
1. Trampoline falls
1. Martial arts
1. Spontaneous with walking in morbidly obese patients
MC in **young males**
25
how are knee dislocations characterized?
MC dislocation?
based upon **direction of the tibia in relation to the femur**
1. **anterior**
1. posterior
1. lateral
1. medial
26
1. **deformity with severe pain** and limited ROM
- **50% will spontaneously reduce**
1. **Ecchymosis and swelling**
1. Assess NV status
- Popliteal artery, common peroneal and tibial nerve injuries
- Limb-threatening vascular injuries are common even with normal pulses
1. Attempt ligamentous assessment
- May be limited due to large effusions
- **Hyperextension >30° when leg is lifted by foot indicates gross instability**
dx?
w/u?
1. **knee dislocation**
2. XR; CT/MRI after reduction and stabilization
27
management for knee dislocation
1. **Reduction** - **_longitudinal traction_**
- Procedural _sedation_
- post-reduction NV check - If _distal pulses are intact_, assess by **ABI / angiography**
- **Immobilize knee in 20° flexion** - Allow access to distal feet for serial NV assessment
- Post reduction imaging
1. Ortho and vascular surgery **consultation**
1. **Admit** for serial NV checks
28
tibial plateau fx MOI (2)
1. _Valgus stress_ = **lateral plateau fracture (MC)**
- High-energy trauma in young patient
2. _Low-energy trauma in osteoporotic geriatric pt_ - Twisting or fall
29
1. Sudden onset of pain after trauma with the **inability to bear weight**
1. Swelling, **joint effusion**
1. (+/-) deformity
1. Limited ROM
1. Assess NV status with ABI
1. Look for evidence of open fx
1. Assess for associated injuries
1. Assess for compartment syndrome
dx?
w/u?
1. **Tibial Plateau Fractures**
2. XR; CT/MTI to evaluate amount of displacement before surgery; CTA if vascular comp
30
this XR is beneficial if AP/lateral are inconclusive in tibial plateau fx
oblique
31
mgmt for tibial plateau fx
1. Initial - Compression, ice, analgesics, splinting in extension
1. _Displaced_ - Most all fractures will require **ORIF**
1. _Non-displaced_
- **Long-leg posterior splint / knee immobilizer**, crutches, strict **non-weight bearing**
- F/u with ortho within 1 week
32
indications for emergent consultation in tibial plateau fx
Open fx, NV compromise, compartment syndrome
33
indications for urgent consultation (within 24-48 h) for tibial plateau fx
1. Fractures with **any displacement or depression**
1. Most all fractures will require **ORIF**
34
* Sudden force to flexed knee with **quadriceps contracted**
* Knee flexion at the beginning of a jump or an awkward landing
dx?
Tibial Tubercle Fracture
35
1. **MC in children** - Bones with open growth plates
1. Pain, tenderness, and swelling over **tibial tuberosity**
1. **Displacement of patella _superiorly_**
1. Loss of ROM
dx?
w/u?
mgmt?
1. tibial tubercle fx
1. XR knee - 2 views
1. mgmt
- _Incomplete/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 h)**
36
**Most common long bone fracture**
Most often in association with fibular fracture
Tibial Shaft Fracture
37
MOI of Tibial Shaft Fracture (adults & children)
* Adults: high-energy direct blow to the tibia
* Children: twisting injury
38
presentation of tibial shaft fx
1. inability to bear weight
1. Pain, swelling, deformity
1. Assess for common complications: **Open fracture, NV compromise, Compartment syndrome**
39
diagnostics for tibial shaft fx
1. AP and Lateral Tibia/Fibula **XR** - Add on knee and ankle if associated injury is suspected
1. Add oblique XR / **CT** - Further evaluate complexity of fracture
1. **Bone scan** if occult fx is suspected
40
mgmt for tibial shaft fx
1. Initial - RICE, analgesics, long leg posterior splint
1. _Emergent consultation_ - Open fx, Tib/fib fracture, NV compromise, compartment syndrome
1. _Displaced_
- **Closed reduction and long leg splinting** (posterior + stirrup)
- Admit for observation and monitoring of complications
- Consult ortho
1. _Non-displaced_
- **Long-leg posterior splint**, crutches, **strict non-weight bearing**
- F/u with ortho within 1 week
41
* **Isolated fracture uncommon**, most often associate with tibia fx
* MOI: **Direct blow** to the lower leg; Rotational force
dx?
fibula fx
42
1. May be able to bear weight - if _isolated_
1. **Point tenderness** and localized pain with swelling
1. Deformity may be noted if displaced
1. Assess for **Maisonneuve fx**
dx?
w/u?
1. **fibula fx**
1. XR - 2 views tib/fb; isolated knee/ankle if needed
43
**Proximal fibula fx** with associated **medial malleolus fx** _or_ **ligament disruption of ankle** without fx
what type of fx?
Maisonneuve fracture
44
mgmt for fibula fx
1. RICE, analgesics, long leg posterior splint
1. _Emergent consultation_ - Open fx, tib/fib fracture, NV compromise, crush injuries, compartment syndrome
1. _Displaced/Maisonneuve_ - **Posterior long leg splint**; **Refer within 24-48 hours**
1. _Fibular head/neck fx_ - **Knee immobilizer splint / long leg posterior**; Ortho within 1 week
1. _Distal fibula fx_ - **Stirrup splint / air-cast splint**; Ortho within 1 week
45
what type of fibula fx may begin early weight bearing using crutches as needed
Isolated, non-displaced fibular fractures
46
how to inspect/palpate **anterior** view, standing, and supine for _foot and ankle exam_
1. Note the **alignment** of the toes, the position of the foot in relation to the limb, and the medial curvature of the forefoot
1. **Palpate** plantar fascia, MTP joints, and head of metatarsal for sesamoid bone tenderness
47
* how to inspect and palpate **posterior** view in _foot and ankle exam_?
* what is normal?
1. Assess **heel alignment** - while standing
- _Nml_: neutral or slight valgus (turned-out heel) with no more than 1-2 lateral toes visible from behind
1. Palpate **Achilles tendon insertion**
48
how to inspect and palpate medial view in foot and ankle exam
inspect while standing
1. **Arch**
- Should be symmetric
- High arch (pes cavus)
- Flatfoot posture (pes planus)
1. **Prominence of medial midfoot** - Accessory navicular bone
1. Palpate for **perimalleolar tenderness**.
49
how to inspect and palpate lateral view in foot and ankle exam
inspect while standing
1. Inspect for calluses, ankle swelling, or prominence of the posterior calcaneus
1. Palpate for perimalleolar tenderness
50
how to inspect pt while standing on their toes
1. Note symmetry
1. Heels should move into a normal slight-varus position
51
how to assess gait in foot and ankle exam
1. Analyze alignment of the foot during the different phases of gait - Heel strike, mid stance, toe-off, swing phase
2. Look for obvious limp, lurch, dragging of the feet, in-toeing, out-toeing, and drop-foot gait
52
1. how to assess ROM in foot and ankle exam?
1. normal degree of range of ankle, foot, and toes?
Starting position - the foot is perpendicular to the tibia
1. Ankle: Plantar Flexion 0-50°; Dorsiflexion 0-20°
1. Foot: Inversion 0-35°; Eversion 0-25°
2. Toes: Flexion 0–30°; Extension 0–80°
53
specific muscle testing for Posterior tibialis
Resist as patient inverts and plantar flexes
54
specific muscle testing of Anterior tibialis
Resist as patient inverts and dorsiflexes the foot
55
specific muscle testing of Peroneus longus and brevis
resist eversion
56
specific muscle testing of Extensor hallucis longus
Resist dorsiflexion of the great toe
57
specific muscle testing of Flexor hallucis longus
Resist plantar flexion of the great toe
58
3 special tests of foot and ankle exam
1. Anterior Drawer Test
1. Talar Tilt Test
1. Thompson's Test
59
Excessive anterior translocation of the foot is indicative of anterior talofibular ligament instability
what test?
Anterior Drawer Test
60
what is the talar tilt test?
Tests 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 ligament - dorsiflexion with inversion and eversion
61
what is the thompson's test?
Compression of the calf in a prone position should produce plantar flexion. Absence of this finding indicates achilles tendon rupture
62
imaging choice for the ankle?
Ankle Series
1. AP
1. Lateral
1. _Mortise_: Provides a better view of the ankle joint
63
Ottawa ankle rules for XR
Radiograph if 1 is present
1. Pain at the malleoli
1. Inability to bear weight 4 steps
1. Tenderness posteriorly or inferiorly at the malleoli
64
imaging choice for the foot
Foot Series
1. AP
1. Oblique
1. Lateral
65
ottawa foot rules for XR
Radiograph if 1 is present
1. Inability to bear weight for 4 steps
1. Tenderness at base of 5th metatarsal
1. Tenderness over navicular bone
66
* **Occurs 5-7 cm from insertion site on calcaneus**
* MOI → **Direct (blow)** or indirect (**forced dorsiflexion** - stop and go sports)
which type of achilles tendon injury?
rupture
67
1. **Occurs at insertion site**
1. MOI: indirect as above
which type of achilles tendon injury?
tear
68
1. Often reports **“pop”** sound with sudden **severe pain**
1. Difficulty bearing weight
1. **Palpable defect**
1. **Weak active plantar flexion**
1. **(+) Thompson test**
dx?
achilles tendon **rupture**
69
Less acute/severe pain than a rupture
Localized tenderness over insertion site
**No palpable defect**
dx?
achilles tendon **tear**
70
w/u and mgmt for achilles tendon injury
1. Diagnostics - **Ankle x-ray;** **_MRI/US confirms_**
1. RICE, Follow up with ortho within 1 wk
- _Rupture_: **Short leg posterior splin**t in slight plantar flexion; Non-weight bearing; Surgical vs non-surgical management
- _Tear_: Controlled Ankle Motion **(CAM) boot** and PT
71
MOI of achilles tendonitis
**Microtrauma** from repetitive stress who has increased their training program or is training rigorously for a long period of time
72
1. **Burning pain** and **stiffness** _2-6 cm above posterior calcaneus_ - Worse with activity and relieved with rest
1. **_(-)_ Thompson test**
1. No defect noted
1. ROM and MS normal
1. Long-standing dx may result in palpable **calcaneal spur**
dx?
w/u?
mgmt?
1. **achilles tendonitis**
1. clinical dx
1. Rest, ice, NSAIDs x 7-10 d; Chronic or no improvement - Refer to PT
73
classifications of ankle sprains?
MC?
Classified based upon _location & severity_
1. **Lateral ankle sprain - MC**
1. Medial ankle sprain
1. High ankle sprain
74
cause of lateral ankle sprain?
damage of what ligaments?
**Inversion** injury
Damaged to _anterior talofibular ligament or calcaneofibular ligament_
75
cause of medial ankle sprain?
damage to what ligament?
* **Eversion** injury
* Damage to the _deltoid ligament_
76
cause of high ankle sprain?
damage to which structure?
* Severe inversion
* Damage to the _tibiofibular syndesmosis_
77
1. h/o **fall / twisting injury**
1. pain, swelling, ecchymosis, difficulty ambulating
1. Localized **point tenderness over involved ligament** - Assess both malleoli and 5th metatarsal base
1. Decreased ROM
1. **Squeeze test** - _Pain over the distal tib/fib_ (damage to tibiofibular syndesmosis)
1. **(+) Talar Tilt** with pain with individualized tendon maneuver
1. **(+) Anterior drawer** with _anterior talofibular injury_
dx?
w/u?
1. **ankle sprain**
1. ankle series - *if fits ottawa ankle rules*; _nml_ *unless* high ankle sprain (Tibiofibular syndesmosis widening)
78
phase 1 mgmt of ankle sprain
*most important in management plan*
1. RICE with NSAIDs
1. Aircast splint or ankle brace (rarely a cast for high grade injuries)
1. wt bearing as tolerated - crutches if severe pain
79
phase 2 mgmt for ankle sprain
1. start once wt bearing w/o pain (appx. 2-4 wks after injury)
1. Continue splint
1. Start strengthening exercises and achilles stretching
- Writing “ABC’s”, ROM with elastic band, heel raise
80
phase 3 mgmt for ankle sprain
1. Start once full ROM has returned and strength is up to 80% of normal
1. Wean ankle bracing
1. Increased strength exercise intensity - One leg balance, running figure eights
1. Refer to PT if limited ROM and pain after 2-3 wks of home therapy
81
Indications for referral to ortho for ankle sprains
Nerve injury, hx of chronic instability, failure to improve after 6 wks
82
classifications of ankle fx
Classified based upon location and ligamentous involvement
1. **Unilateral fracture without ligament disruption (stable)**
1. **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
83
1. Pain and swelling
1. **Point tenderness** and limited ROM
- Identify if point tenderness is only over the malleoli or if ligaments are affected
1. **Palpate proximal fibula** for tenderness (Maisonneuve fx)
1. Assess NV status
dx?
w/u?
1. ankle fx
1. Ankle XR series; CT ankle
84
mgmt for ankle fx
1. _Emergent ortho evaluation_: Open fracture, NV compromise, associated dislocation
- _Unstable and displaced_ - **ORIF**
1. _Unstable, nondisplaced fracture_
- **Short / long leg splint/cast**; **_non-weight bearing_**
- F/u with ortho with in 7 days
1. _Stable fracture_: **wt-bearing splint/cast** x 4-6 weeks
1. _Suspected occult fracture_
- **Short leg splint and repeat x-ray in 10-14 d**
- Repeat x-ray in 10-14 days will reveal a **bony callus around occult fracture** as healing begins
85
MC calcaneal fx?
tarsal bone fx
86
MOI of calcaneal fx
Results from **axial loading**
Often associated with vertebral fx
87
1. Severe pain in heel with **inability to bear weight**
1. Swelling, ecchymosis and deformity may be present
1. Assess NV status
- Cap refill preferred or doppler - Distal pulses may be diminished due to swelling
1. **Assess lumbar spine for tenderness**
dx?
w/u?
1. **calcaneal fx**
1. **XR** - foot & ankle series, lumbar XR if (+) exam; **CT** for further eval or need for surgery
88
mgmt for calcaneal fx
1. RICE
1. _Well padded_ posterior short leg splint
1. Non-weight bearing
1. Ortho consult with in 24 hours
- **Displaced fractures require ORIF**
- **Non-displaced fx** may be tx **conservatively with serial XR** to ensure displacement doesn’t occur
89
2nd MC tarsal fx
talar fx
Anatomic Considerations: Extensive blood supply; At risk for AVN
90
MOI of talar fx
High force plantarflexion, dorsiflexion or inversion force
presentation as same as calcaneal fx
91
w/u & mgmt for talar fx
1. Foot & ankle series; CT for further evaluation of fracture is surgery is considered
1. Same as calcaneal fx
92
Displacement of the talus from the tibia
dx?
ankle dislocation
93
types of ankle dislocation?
which is MC?
MOIs of each?
1. **_Posterior_ - MC**
- MOI: Posterior force on plantar flexed foot
2. **Lateral**
- MOI: Forced inversion, eversion, or external or internal rotation of ankle
**highly unstable** - Disruption of lateral or medial ligaments and/or the tibiofibular syndesmosis
94
1. Grossly **deformed**
1. Posterior dislocation - Locked in plantar flexion with the anterior tibia easily palpable
1. Assess NV status - If _vascular compromise_, reduction should not be delayed for imaging
dx?
w/u?
mgmt?
1. **_ankle dislocation_**
1. Ankle/foot series; CT/MRI often needed to further assess associated fx or ligamentous damage
1. **reduction; consult ortho ASAP**
- Procedural sedation
- Grasp heel and foot and apply **downward traction**
- **posterior leg splint**
- Reassess NV status
- Obtain post reduction films
95
1. MOI: Twisting or rotational force; Blunt trauma (item dropped on foot)
1. Pain with weight bearing
1. Swelling, ecchymosis, and tenderness over site - In stress fractures, may only demonstrate tenderness
1. Fracture at base of 5th metatarsal = **Jones fracture**
dx?
w/u?
mgmt?
1. **metatarsal fx**
1. foot series; CT if XR nml and still sus
2. mgmt
- _Single nondisplaced metatarsal neck and shaft fx_: Short leg posterior cast or fx brace; wt-bearing is permitted
- _Multiple fx or displaced/angulated fx_: Consult for open/closed reduction
96
AKA: **Lisfranc joint**
A disruption of tarsometatarsal joint (Lisfranc injury)
often associated with fx of the metatarsals and tarsals
dx?
Tarsometatarsal Injury
97
1. An **axial load placed on a plantar-flexed foot**, followed by **forcible rotation, bending, or compression.** - Crush injuries, high-impact accidents such as a MVA, or high-impact sports
1. **Midfoot pain**/tenderness
1. Inability to bear weight
1. **(+) deformity**, swelling, ecchymosis
1. Assess for compartment syndrome and NV injury
dx?
w/u?
1. **Tarsometatarsal Injury**
1. **_Wt bearing_ foot series**, Often _BL images for comparison_; **CT/MRI** if clinical suspicion but nml x-rays
98
mgmt for tarsometatarsal injury
1. **_Non-displaced_**
- **Non-wt bearing splint/cast** (short-leg posterior) x 6-8 wks
- **rigid arch support x 3 mo**
2. **_Displaced fracture/TMT joint_**
- **Splint** as above
- **ORIF**
99
MC phalangeal fx
5th phalanx
100
MC phalangeal dislocation
MTP of the 1st joint
101
presentation of phalangeal injury?
w/u?
mgmt?
1. Pain/tenderness, swelling, ecchymosis, deformity, limited ROM
1. Foot series
1. Mgmt
- _Non-displaced fx_: **buddy tape**
- _Displaced/angulated_: **reduce w/ local anesthesia and buddy tape**
- _Dislocation_: **digital block with traction reduction** - Repeat post reduction films
102
what is Hallux Valgus?
MC in who?
cause?
AKA: Bunion
1. **Lateral deviation of great toe** at **metatarsophalangeal (MTP) joint**
1. 10x in females
1. Caused by **tight fitting shoes and osteoarthritis**
103
presentation of hallux valgus
w/u?
mgmt?
1. Pain and swelling of **1st MTP joint** - Aggravated by shoe wear; most have nml ROM
1. **Foot series** - Measure valgus angulation at the MTP joint
2. **Pt ed**: shoe wear mods (wide shoes, stitching patterns over bunion, avoid high heels); **refer** to ortho for surgery (still symptomatic even with conservative tx)
104
nml angle measurement of MTP joint
< 15°
105
what is Morton’s Neuroma?
MC where?
MC in who?
1. A **perineural fibrosis of common digital nerve** as it passes between the metatarsal heads
1. MC **base of 3rd & 4th toes** - 3rd web space
1. 5x **females** - Likely related to compression of the nerve by tight shoes
106
1. **Plantar pain in the forefoot** - **Burning**; Aggravated by activity, wearing high heeled or tight shoes; Relief with rest
1. **Dysesthesias** into affected two toes
1. feel as though they are **“walking on a marble”** or there is a wrinkle in their sock
1. **(+) Interdigital Neuroma Test** - increased _tenderness and pain radiating into the toes_
dx?
w/u?
mgmt?
1. **Morton’s Neuroma**
2. XR (nml), MRI/US can detect neuroma but findings are inconsistent
3. _MC nonsurgical tx_ - **pt ed** (low heeled, well cushioned, wide toe box, metatarsal padding); **CSI**; **surgical excision** if sx persist or recur
107
1. One of the **MCC of heel pain** in adults
1. Peak incidence between ages 40-60
1. Etiology not well understood
1. Risk factors: Obesity, flat feet, prolonged standing/jumping
dx?
Plantar Fasciitis
108
presentation of plantar fasciitis?
w/u?
1. **Insidious onset**
1. **Heel pain** - worse when initiating walking
- **most severe during their 1st steps in AM** (or after long period of inactivity/sitting)
- lessens with walking
- Worsens toward end of day d/t prolonged wt bearing
- Relieved by sitting
1. **Tenderness directly over medial calcaneal tuberosity and 1-2 cm along the plantar fascia**
1. **Passive dorsiflexion** of toes may cause increased pain
XR to r/o other conditions
109
mgmt of plantar fasciitis
1. Non-surgical MC
- _Initial_: **OTC orthotic heel pad and home stretching program**
- Avoid barefoot walking & flat shoes, activities that may be causative (dancing, running)
- Ice and NSAIDs
- May take 6-12 mo to resolve
1. _Unresponsive_
- **CSI** into heel
- **Custom orthotic**
- **Surgical**: _partial release of plantar fascia_
