Rearfoot Pathology--------------exam3 Flashcards Preview

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Flashcards in Rearfoot Pathology--------------exam3 Deck (33):
1

1st met cuneiform exostosis

Clinical presen

Pain w shoe P
Deep aching pain after rest
Palpable mass
Sweelong

2

Clin

Redness, erythema

EHL tendinitis

Burning, tingling, numbness-MDCN neuritis

Ulceration

3

1st met cunei exostosis

Conservative treatment

Padding
Shoe modif- extra depth, lacing
Physical therapy
Injection of corticosteroid

4

1st met cunei exostosis

Surgical treat

Surgical resection (exostectomy)

Arthrodesis- severe DJD

5

Os trigonum syndrome

-Triangular ossicle located at the posterior aspect of the talus adjacent to the lateral tubercle

-Ossicle can be united to the posterior aspect of the talus by cartilaginous, fibro- cartilaginous, or fibrous tissue

-May be caused as a result of a developmental anomaly or pathologic fracture ???

6


Os Trigonum Syndrome

 Mechanism of fracture is extreme ankle plantarflexion
- Example: ballet dancers



Can predispose FHL tendon to chronic inflammation

7

Os Trigonum Syndrome

Associated terminology. . .


- An enlarged posterior extension of the lateral tubercle of the talus = Steida's process

- Fractures of the posterior lateral tubercle = Shepherd's fracture

8

Os Trigonum Syndrome

 Treatment


- Immobilization
- Physical therapy
- Injection of corticosteroids
- NSAID's
- Excision

9

Os Tibiale Externum


 Ossicle of varying size, shape, and position which may be found adjacent to the navicular tuberosity

 Dwight classification -3 variants

10

Os Tibiale Externum

Type I

- small ossicle (sesamoid) within posterior tibial tendon

- sesamoid is characteristically round and small in size

- located at a distance from the navicular tuberosity

- usually asymptomatic

11

Os Tibiale Externum

Type II

- larger then type 1
- oval or semi-circular in shape

- accessory navicular proximal to navicular

- in close apposition to the tuberosity

- it may be attached by cartilage or fibrocartilage, or it may articulate with the tuberosity containing true synovial tissue

- usually most symptomatic

12

Os Tibiale Externum

Type III

- enlarged tuberosity


- secondary to the accessory ossification center being fused to the tuberosity

- other names:
cornuate navicular, gorilliform navicular

- symptoms related bony prominence

13

Os Tibiale Externum

Clinical Presentation


- pain to palpation to medial prominence
- may palpate motion of bone fragment
- pain upon resistance to supination

- inflammation over the area
shoe irritation, adventitious bursa

14

Os Tibiale Externum

 Treatment


- Padding
- Orthotics
- Immobilization
- Physical therapy
- NSAID's
- Surgical Excision

15

Posterior Tibial Tendon Dysfunction (PTTD)

(seen in middle-age and elderly females)


 Painful progressive deformity resulting from a gradual stretch (attenuation) of the PT tendon as well as the ligaments that support the arch of the foot

 Most common cause of adult acquired flatfoot deformity

16

PTTD

- Function (posterior tibial tendon)


- Supports medial arch

-Decelerate STJ pronation(after heel contact)

- Invert and plantarflex the foot

17

PTTD

 The etiology of PTTD is multifactorial

 Two categories:

1. Traumatic (uncommon)
ex: laceration and avulsion at navicular tuberosity

2. Degenerative
- Often due to an intrinsic abnormality of the tendon itself

- A chronic inflammatory process, such as tenosynovitis, can cause tendon degeneration, tendon elongation or attenuation, interstitial tearing, and eventually rupture

18

PTTD

Predisposing Factors

- Overuse
- Pre-existing flatfoot/
pronation
- Tenosynovitis
- Systemic inflammatory disease
- Accessory ossicle
- Corticosteroids
- Tendon hypovascularity
- Obesity
- HTN
- DM

19

PTTD

Clinical presentation

- Usually no history of trauma


- Patient complains of “fallen arches”

- Unilateral progressive flatfoot with calcaneal valgus

- Swelling, warmth and tenderness along tendon

- Lateral calcaneal fibular impingement pain

- may see sinus tarsi syndrome

20

PTTD

The location of pain can change as the deformity progresses

21

PTTD

 Clinical presentation continued . . .


- “Too many toes sign”
- Unable to perform a single heel rise
- unable invert heels
- Decreased manual muscle testing against resistance

22

PTTD

 “ Too many toes sign”


- forefoot abduction

- posterior view

- more toes are visible
in relation to the lateral surface of the leg on the pathologic side as compared with the normal foot

- Usually 1 1⁄2 toes is normal

23

PTTD

 Single heel rise test

- Patient asked to rise up on the ball of the affected foot while the non-affected foot is held off the ground

- Sequence of activation
1. PT tendon- inverts and locks hindfoot
2. Gastrocsoleus muscle group- pulls up heel to
complete heel rise

24

PTTD

Myerson added a 4th stage


- characterized by valgus angulation of the talus and early degeneration of the ankle joint

25

PTTD

Conservative Treatment

Immobilization

Physical therapy

NSAID

foot orthoses

Ankle foot orthoses

26

PTTD

 Surgical Treatment
- primary repair


- PT tendon augmentation

- calcaneal osteotomies

- fusions


27

Sinus Tarsi Syndrome

 Sinus tarsi definition:

- anatomic space between the inferior neck of the talus and the superior aspect of the distal calcaneus

 Forms part of the subtalar joint

 Contains small vessels and nerves, subtalar
ligaments as well as fat and connective tissue
- Hoke’s tonsil

28

Sinus Tarsi Syndrome


 Chronic pain over the sinus tarsi and lateral foot and ankle


 Often associated with a sensation of rearfoot instability

 Often associated with trauma example: ankle sprain

29

Sinus Tarsi Syndrome

 Non-traumatic cases


- Pes planus/Excessive pronation

- Tarsal Coalition

- Osteoarthritis

- Inflammatory arthritis

30

Sinus Tarsi Syndrome

Clinical Presentation

- Minimal edema

- Pain elicited by supination

- Pain elicited by direct palpation

- Rapid relief with sinus tarsi block

- Aggravated by ambulation

- Improved with rest

31

Sinus Tarsi Syndrome

 Conservative Treatment

- Physical therapy
- Injections
- NSAIDS
- Orthotics
– limit pronation
- Immobilization

32

Sinus Tarsi Syndrome

 Surgical Treatment


- Evacuation of contents of sinus tarsi

- denervate the sinus tarsi

- Arthroscopic examination and debridement of the posterior subtalar joint and sinus tarsi

33

1st metatarsal- cuneiform exostosis

Saddle bone deformity

Chronic 1st hypermobility- leads to the dorsal jamming at the 1st met-cuneiform joint

Flexible high arched feet- more prone or hypermobile PF 1st ray