Shelbie Flashcards
(10 cards)
Subtalar Instability
Subtalar (Talocalcanean) Joint:
- synovial joint with 3 degrees of freedom
- resting position: midway between extremes of ROM
- closed packed position: supination
- capsular pattern: limited varus, valgus
- intrinsic ligaments:
interosseous talocalcaneal lig., cervical lig., medial, lateral, and posterior talocalcaneal ligs.
- extrinsic ligaments: calcaneofibular lig., tibiocalcaneal band of deltoid lig.
The interosseous talocalcaneal ligament is the primary restraint of the subtalar joint. Failure of this ligament results in instability.
History:
- acute inversion injury
Symptoms:
- recurrent “rolling over” or “giving away” feeling
- recurrent swelling
- painful stiffness
- aggravation during sports & walking on uneven surfaces
- more secure in high top shoes
Acute Clinical Presentation:
- lateral ecchymosis/hematoma, swelling, tenderness localized in the sinus tarsi
- increased amount on inversion
- severe pain
Chronic Clinical Presentation:
- lateral tenderness
- moderate pain
Special Tests:
The sinus tarsi is a small bony canal under the talus.
The talar tilt test is a combination of internal rotation & varus stress on the calcaneus. A positive talar tilt includes a medial shift of the calcaneus causing a unstable increase in the talocalcaneal angle.
Imaging:
Varus Stress View: tests for ligament insufficiency
Abnormal results include:
- talar tilt greater than or equal to 3 mm or greater than or equal to 10 degrees in the lateral ankle joint when compared to the other side.
Conservative Treatment:
- global strengthening of the ankle & hindfoot targeting the static & dynamic ankle stabilizers & peroneals
- Achilles tendon stretching
- balance & proprioception exercises
- bracing to reduce joint motion & irritation
- UCBL orthotics, high top shoes
Surgical Treatment:
- arthroscopic investigation
- Surgical options: anatomic repair of the lateral ligament complex using suture anchors, augmentation with a free plantaris tendon graft or allograft tendon with anatomic placement may be performed for reconstruction of the AFTL and CFL, but for both options, reinforcement with the inferior extensorretinaculum is recommended.
Aseptic Necrosis of Navicular Bone (Kohler’s Disease)
Aseptic (Avascular) Necrosis: poor blood supply to the bone, resulting in bone death
Kohler Disease: navicular aseptic necrosis in children
Cause:
The exact cause is unknown, no genetic link, believed to be linked to injury resulting in delayed formation of the bone. Secondary to growth demands, blood supply to the navicular bone increases. When ossification is delayed, weight-bearing stresses compress the navicular bone, which leads to ischemia.
Presentation:
- unilateral
- painful swollen foot
- tenderness along the length of the arch
- increased pain with weight-bearing activities causing an antalgic limp
Imaging:
There are no special tests for this specific condition. This diagnosis can be confirmed with radiographs showing a collapsed, flat, radio-dense navicular bone.
Treatment:
Kohler’s Disease is a self-limiting disease, meaning that is resolves on its own without any long-term consequences. Treatment is usually conservative including NSAIDs and reduced weight-bearing. A walking short leg cast with toe extension is recommended, as well as moderate varus (10-15 degrees) so that the navicular is released from posterior tibialis strain.
Aseptic Necrosis of Navicular Bone (Mueller-Weiss Syndrome)
Aseptic (Avascular) Necrosis: poor blood supply to the bone, resulting in bone death
Mueller-Weiss Syndrome: navicular aseptic necrosis in adults
Cause:
exact cause is unknown, could be linked to a stress fracture of the navicular, but it’s defined as, spontaneous collapse of the lateral portion of the navicular combined with a medial protrusion of the talar head.
Presentation:
- chronic, severe pain of the midfoot
- progressive deformity
- bilateral
Imaging:
T1-weighted sagittal view of foot showing navicular bone death.
Treatment:
First treated conservatively with analgesics and orthotics, but if conservative treatment fails, surgery is considered, involving arthrodesis of the talonavicular and naviculocuneiform joints.
Cuboid Rotation
Disruption of the arthrokinematics or structural congruity of the calcaneocuboid joint insidiously or after a traumatic event.
Cause:
The exact mechanism is unknown, but excessive pronation, overuse, and inversion ankle sprains can contribute, but forceful eversion of the cuboid while the calcaneus is inverted results in calcaneocuboid joint disruption.
Presentation:
- lateral foot pain in the area of the cuboid
- erythema, edema, ecchymosis
- sulcus of the dorsum of the cuboid, or prominence on palmar surface
- tenderness over theperoneousl ongus tendon, cubital groove, & origin of the extensor digitorum brevis muscle
- limp
- weakness with side-to-side movements
Special Tests:
Midtarsal Adduction Test: with the calcaneus stabilized, the midtarsal joint is manipulated passively in the transverse plane.
Midtarsal Supination Test:
stabilize the calcaneus while adding an inversion and plantar flexion force to the midtarsal joint.
Dorsal-plantar Cuboid Shear Test: cuboid is passively translated dorsally or plantarly to reproduce pain.
Imaging:
Due to the variations in foot anatomy, diagnosis of cuboid rotation can be difficult.
Treatment:
Cuboid Whip Manipulation:
Thumbs on plantomedial aspect of cuboid, 70-90 degrees knee flexion, 0 degrees dorsiflexion. whip foot into inversion an plantarflexion during a low amplitude velocity thrust.
Cuboid Squeeze:
Slow stretch in to maximum plantarflexion. When the dorsal tissues are relaxed, the cuboid is squeezed. Immobilization and orthotics is recommended for people who don’t experience relief from the manipulations.
Navicular Stress Fracture
Cause:
- sudden changes in direction, jumping, sprinting
- overuse
Presentation:
- pain
- swelling
- discoloration
- reduced ROM/strength
Special Tests:
N Spot: locate talonavicular joint by inverting and everting the foot and palpating the dorsal proximal portion of the navicular.
Imaging: MRI
Treatment: Conservative treatment includes complete non-weight-bearing in a full cast for about 6 weeks. Then gradual return to full weight-bearing. If conservative treatment fails, surgery may be required with a pin or screw. In order to return to play, an ankle mobility and strengthening protocol should be determined.
Midtarsal Periostitis
Periostitis: inflammation of the covering of the bones, precursor to stress fracture
Cause:
- overuse and stress
Presentation:
- local tenderness over the metatarsal region
- common in pronated feet
- stress fracture-like symptoms
Imaging:
Radiograph showing a high-lighted outline of the metatarsal bones.
Treatment:
Follow the RICE protocol. Avoid sandals and wear soft soled shoes. Orthotics will help reduce the strain and limit the motion.
Midtarsal Rheumatoid-type Arthritis
RA: auto-immune disease, that is chronic and debilitating, specifically attacking joints throughout the body.
Cause:
The exact cause is unknown, but there is a genetic component, which is triggered by an environmental or chemical factor.
Presentation:
- bilateral symptoms
- pain, swelling, stiffness
- deformities: bunions, claw toes, painful bumps on the ball of the foot creating calluses
- tenderness
Imaging:
Radiograph as first order imaging.
Treatment:
Refer patient to rheumatologist. The options to manage symptoms include: rest, ice, NSAIDs, Orthotics, custom braces, steroid injections. Fusion is the most common surgical treatment for RA.
Midtarsal Ligamentous Contracture: Equinus
Equinus: inability of the ankle joint to dorsiflex sufficiently, contributes to a wide variety of other foot diagnoses
Cause:
- Achilles tendon tightness
Presentation:
- limited ROM, inability to bend properly at the ankle
- calf cramping
- pain
Special Tests:
Silfverskoid Test: full knee extension, with the subtalar joint in neutral, supinate the forefoot, dorsiflex the foot and measure the angle of dorsiflexion at the ankle. Repeat the test with the knee in 90 degree flexion.
if there is less dorsiflexion when the knee is extended, this indicates a gastroc equinus. if there is limited dorsiflexion during both knee extension and knee flexion, it could indicate a soleal equinus or an osseous block. A soft, spongey end range indicates a contracture, a hard end signifies a bony block.
Imaging:
Radigraph, help rule out other diagnoses.
Treatment:
Conservative treatment includes: night splints, heel lifts, orthotics, and PT to reduce tightness. Surgical intervention in the form of an Endoscopic Gastrocnemius Resection (EGR) is a minimally invasive option that is usually very successful in the treatment of Equinus deformity.
Midtarsal Subacute Arthritis
Arthritis is a degenerative joint condition.
Cause:
- trauma
- flatfoot deformity
Presentation:
- dull pain, discomfort, increased with walking
- insidious onset
- tender, bony prominences
- limp
- unilateral in middle aged adults
- bilateral in adolescence
Special Tests:
Piano Key Test: stabilize midfoot, while applying a dorsal stress to the distal metatarsal
Treatment:
Conservative treatment includes: modified rest and relief from weight-bearing, strapping the joints in varus and supination, and tilting the heel in varus position with a medial wedge.
Midtarsal Strain
Chopart’s Joint: talonavicular joint and the calcaneocuboid joint
Ligaments Involved:
Dorsal Calcaneocuboid Ligament (CL): joins the calcaneus and cuboid on the superior foot
Bifurcate Ligament (BL): Y shaped ligament consisting of 2 parts (calcaneonavicular and calcaneocuboid).
Cause:
- more common in running and jumping sports
- increased risk in people with fallen arches
CL Presentation:
- pain and swelling on external and superior region
- pain upon foot inversion
BL Presentation:
- pain on external region
- pain upon plantar flexion and supination
Treatment:
Taping/bracing, NSAIDs, orthotics, steroid injections, immobilization are all conservative treatment options. If conservative treatment fails, surgery may be required.
