Lower Leg, Ankle, & Foot

Tests for ankle ligamentous instability:

(1) Anterior Drawer test: Anterior talofibular ligament (2) Talar tilt: Calcaneofibular ligament (pt in sidelying & slight PF)

Lateral ankle major anatomy:

(1) Anterior talofibular Ligament (ATF) -Taut when the ankle is plantarflexed and inverted. (2) Calcaneofibular (CFL) Ligament -Taut when the ankle is dorsiflexed and inverted (3) Posterior talofibular (PTF) Ligament -Is taut in eversion and is rarely injured

Other names for shin splints:

(1) Exercise Related Leg Pain (ERLP) -Pain between knee and ankle which is associated with exercise (2) Anterior Tibial Stress Syndrome (ATSS) Pain along the anterolateral aspect of the shin (3) Medial Tibial Stress Syndrome (MTSS) Pain along the posteromedial border of the distal 2/3 of the tibia

STRESS FRACTURES: Two Main Types

(1) Fatigue Fractures: Abnormal stress on normal bone (2) Insufficiency Fractures: Normal stress on abnormal bone

Achilles tendonitis typically occurs as one of two types of tendonitis:

(1) Insertional: Involves the tendon bone interface (2) Non-insertional: Occurs proximal (approx 6cm) to the tendon insertion on the calcaneous in or around the tendon substance.

Two literature supported theories of Medial Tibial Stress Syndrome

(1) MTSS is a periosteal modeling to reinforce the tibia at its narrowest diaphyseal cross section - which bears the greatest stress with loading. • Calf muscles cause a repeated bending/bowing of the tibia thereby causing a stress reaction and periosteal reaction. (2) Inflammation of the periosteum (periostitis) due to excessive traction on muscle fibers of the deep posterior / medial compartment (soleus) and fascia at their attachment site to the medial border of the distal tibia (diffuse tenderness along the tendon of the tibialis posterior or soleus)

Functional Progression of the treatment for a lateral ankle sprain is based upon:

(1) ROM (2) Strength (3) Stability (4) Performance--3C's -Carriage (are they symmetrical in loading) -Control (can they start/stop a movement with undue stress) -Confidence

Clinical Evaluation for a syndesmotic sprain

(1) Squeeze Test -Compress the proximal tibia and fibula. -Pain at the level of the ankle indicates a positive test. (2) External Rotation Stress Test -Place the ankle in a position of dorsiflexion and apply and external rotation force. -Pain at the level of the ankle indicates a positive test. (3) Wedge Test -Place ankle in DF (4) Inferior Tibiofibular ligament test -Glide distal end of fibula posteriorly

Talar Tilt Test

(1) To test the Calcaneofibular Ligament: Neutral & Inversion (2) To test the ATFL: PF & Inversion (3) To test the PTFL: DF & Inversion

Tibial fracture treatment

(A) Undisplaced fractures are usually treated conservatively in a long leg cast for approximately 6-12 weeks. -A knee hinge is usually inserted in order to allow knee movements and decrease knee stiffness afterwards. (B) Displaced fractures need to be reduced in order to realign the leg into a more anatomic position. -The reduction is usually maintained by internal fixation using an intramedullary nail. -This allows for early mobilization. REHABILITATION: -Should be started as early as possible. Follow general principles of fracture management. -Return to full unrestricted ADL is expected at around 6 months in uncomplicated injuries.

• Test for peroneal tendon dislocation:

(Lateral ankle pain complaint) -The tendons are trying to ride up & over the lateral malleolus -Prone; hold in DF and get them to point toes to see if the tendons ride up -usually surgery is required

Maisonneuve Injury

-An ankle fracture may be accompanied by a fracture of the fibula near the knee - Therefore, the whole fibula must be palpated and radiographs of the whole leg requested when there is tenderness in the proximal fibula.

What do we look for in Chronic Exertional Compartment Syndrome?

-Best results are found when you conduct your evaluation soon after the activity that provokes the results -Burning in leg and numbness in dorsum of foot that resolves within 30 min of run -Pain with passive stretching -Firmness of involved compartment -Palpable muscle hernias due to fascial defects are present 40-60% of the time

Chronic Exertional Compartment Syndrome treatment:

-Conservative treatment should be offered to the patient initially, BUT only with the knowledge that in a majority of cases, the symptoms will return if the patient returns to the previous level of activity (even if this is delayed by months) -Symptoms tend to only occur with certain activities, and only above a certain intensity. -By avoiding these activities, or by performing them at a lower intensity, the symptoms are likely to resolve themselves. -Only definitive treatment is to undergo a fasciotomy. (Divide the fascia that encompasses the specific leg compartment. -Two small incisions are made along the fascia - relieving the pressure.) -Very high majority of these athletes return to their previous level fairly quickly and without pain -Following the procedure, it is recommended that the patient is mobilized early. This will aid in reducing the risk that the fascial sheath will reform. -Mobilization / walking should begin within 24 of the procedure. -Return to full unrestricted activity is when the wounds have healed at about 3 weeks

Alternate Names for Acute Compartment Syndrome

-Crush syndrome -Anterior tibial syndrome -Peroneal nerve palsy -Volkmann's ischemia (remember -medical emergency!!)

The mechanism of injury for syndesmosis sprains

-Hyperdorsiflexion** -External Rotation of Foot** -Can occur during a pile-up in football -Internal Rotation of the tibia on a planted foot -Can occur with a blow to the lateral leg -Less commonly internal rotation of the foot Commonly combined with a fibular fracture

Achilles Tendon Pathology Dx:

-Listen to patients symptoms -Decreased plantar flexion strength on affected side -Decreased plantar flexion endurance (less number of repeated single leg heel raises than unaffected side) -Arc sign (area of palpated swelling moves with DF & PF)

Tibial stress reactions/fractures include the spectrum of:

-Periosteal reaction (Medial tibial stress syndrome) -Stress fractures

Tarsal Tunnel Syndrome

-Posterior tibial nerve compression in the tarsal canal behind the medial malleolus -Tingling, numbness over the plantar surface

SPRAIN: Medial Ankle

-Rare to be isolated-3% -Usually partial and anterior -Fracture with complete tears -Seen with Maisonneuve's Fracture -Usually you'll see an avulsion fracture (of tibia) before this occurred -Couldn't tell if there was a deltoid ligament tear or an avulsion fracture from a clinical test- need diagnostic imaging

Thompson's test:

-Testing for achilles tear Pt is tall kneeling; Squeeze calf and see if they go into PF (they wouldn't be able to PF if they tore the achilles tendon)

Surgical management of a lateral ankle sprain:

-The primary indication for surgery is a history of recurrent sprain unresponsive to conservative treatment. -Acute III degree (95% surgical) -Acute repair - Primary The Brostrom procedure involves: Re-suturing the ATF Shortening the CFL to original length -Typically use part of the fibularis longus tendon in reconstructions (remember, fibularis longus inserts on the base of the 1st MT)

Achilles Tendon Pathology Tx:

-Treatment should be initiated as soon as possible after the onset of symptoms as these are hard to resolve at a later date. -Relative rest. -Training may need to be decreased by 60-80% -PRICE -Heel lifts/orthotics -Heelcord stretch -Post Tib/Peroneals -NO INJECTIONS

Test for Morton's Metatarsalgia (Interdigital Neuroma) -This condition is characterized by a thickening of the tissues around the nerve due to fibrosis. Usually caused by chronic compression of the interdigital nerve.

-pain plantar surface between the 2nd & 3rd MT heads -sharp pain, tingling -Squeeze ball of foot & see if it reproduces their pain -Shoes are to blame (shoes not wide enough) -Measure toe box weight bearing -tear drop or cookie to get MT's to separate during weight bearing -A metatarsal pad placed PROXIMAL to the symptomatic interspace is helpful.

A bone scan is a very sensitive technique for the detection of stress fractures and can be positive ____ before plain-film radiographs.

1- 2 weeks

Max lift is ____

3/8 inch • Greater than 1⁄2 inch = extrinsic modification to the shoe

most common overuse syndrome of the lower leg

Achilles Tendon Pathology

This "dancer's fracture" occurs as the result of an acute twisting mechanism in inversion.

An avulsion fracture of the base of the 5th MT -Since the fibularis brevis inserts into the styloid process, they are immediately symptomatic.

The lower leg is divided into four muscular compartments: -Each compartment is surrounded by a fascial sheath, which normally expands as the muscle enlarges during exercise. In CECS, the fascial sheath fails to stretch sufficiently in response to exercise- related muscle expansion

Anterior: tibialis anterior, extensor hallucis longus, extensor digitorum longus - DEEP FIBULAR NERVE / Anterior tibial artery Lateral: fibularis longus, fibularis brevis -SUPERFICIAL FIBULAR NERVE Deep posterior: tibialis posterior, flexor hallucis longus, flexor digitorum longus - POSTERIOR TIBIAL NERVE -Posterior tibial artery Superficial posterior: gastrocnemius, soleus - SURAL NERVE ***The anterior (most common) and deep posterior compartments are by far the most common sites affected.

Fibularis Tendon Pathology - Subluxation

Ask the patient to dorsiflex the ankle while holding it plantarflexed and everted - reproduce the symptoms

This deformity is characterized by prominence of the lateral aspect of the fifth toe metatarsal head. ***It is often associated with a pronated foot.

Bunionette (Tailor's Bunion) ***It is often associated with a pronated foot.

Haglund's deformity

Callus formation on the heel, producing a "pump bump" - the result of pressure on the heel -frequently a bone spur or osteophyte acquired through subcutaneous pressure as the result of poorly fitting shoes in adolescent females. -Friction bone spur; not a traction bone spur -Frequently there is associated retrocalcaneal bursitis or Achilles tendonitis.

Retro-calcaneal Bursitis

Characteristic findings: -Pain with a two-finger squeeze just superior and anterior to the Achilles insertion. -Pain with passive dorsiflexion. Seen on MRI - T1 scale Treatment: -Conservatively with shoe modifications (open back) -Heel lift Rarely - bursectomy

-Hyperextension of the metatarsophalangeal joints and flexion of the proximal and distal interphalangeal joints -Usually results from the defective actions of the lumbrical and interosseous muscles that cause the toes to become functionless.

Claw toes

A condition in which the circulation and function of tissues within a closed space is compromised by increased pressure within that space.

Compartment Syndrome

Syndesmosis sprain treatment

Conservative Care: -With mild injury, treat the same as simple sprain (No widening, No osseous avulsion) -Late symptoms: Talar Dome Fx AITFL impingement -Note: Time frame will be much longer than inversion -Circumferential taping at distal tib-fib syndesmosis provides stability for minor high ankle sprains -The most critical factors to success are careful and continual assessment of the patient. Surgical Intervention: -Current Indications are frank diastasis or diastasis on stress radiographs. -Ipsilateral semitendinosis tendon can be used to replace the AITFL and PITFL, along with a syndesmotic screw which helps to approximate the tibia & fibula to allow for proper tension in the healing ligament. -In below knee non-walking cast for 4 weeks. -Screw is removed 6-8 weeks post surgery and patient can begin therapy progressing to full weight bearing approximately 3 weeks post screw removal Complications of screw placement interventions: -Screw breakage/loosening -Stiffness -Morbidity due to prolonged now weight bearing -Joint stenosis can occur due to lack of motion -Must have a second operation to remove the screw Prognosis: -Excellent with patient compliance -Have a tendency to not heal properly due to misdiagnosis with untreated isolated disruption which leads to chronic instability. Complicating factors: -Heterotropic bone formation in the interosseous membrane—takes 4-6 weeks to appear on x-ray -Associated fracture -Late symptoms: Talar dome fracture, AITFL impingement -Obesity

-The cuboid syndrome is due to a rotational subluxation of the cuboid usually with the lateral aspect of the cuboid subluxing in a dorsomedial direction. -Subluxation irritates the joint capsule, ligaments, and fibularis longus tendon -Cuboid is described as subluxed, locked, dropped This can be due to a tight fibularis longus -May also occur following an inversion ankle sprain -40% of pts with a lateral ankle sprain will have residual symptoms -Excessive pronation -The patient will complain of gradual lateral mid-foot pain, particularly on weight bearing. -Feels like walking with a small stone in their shoe -Maximal tenderness with plantar pressure to the cuboid -Results from plantarflexion/ inversion ankle sprain

Cuboid Syndrome

Talocrural Joint arthrokinematics:

During dorsiflexion, the talus rolls anteriorly and it glides posteriorly. While with plantarflexion, talus rolls posteriorly and glides anteriorly. (talus is convex)

Stress reactions/fractures treatment:

Early diagnosis and rest provide the mainstay of treatment of these injuries. -In the case of periosteal reactions and medial tibial stress syndrome, rest from impact loading for 3-6 weeks is usually sufficient (could have to have relative rest for up to 4 months though) -With a medial tibial stress fracture, the rest period should be 6-8 weeks and may also include a period of non-weight bearing (NOTE: With Anterior tibial stress fracture, immobilization may be as long as 4-6 months.) -Patient should maintain fitness level with non-impact activities. (cycling, swimming, water running, alter-g) -Weight bearing activities are gradually introduced after this period. Treatment may also take the form of: -Footwear advice: Both day use and sports use -Stretching and strengthening routines -Advice about adjusting training routines and/or running surfaces -Attempt to improve shock absorption ability -Biomechanically oriented corrections for uncontrolled pronation: Taping and padding for foot problems Temporary or permanent orthotic devices Follow up gait analysis to adjust orthoses and monitor progress.

-This deformity is characterized by limited dorsiflexion (less than 10 degrees) at the talocrural joint. -Usually the result of contracture of the gastrocnemius or soleus.

Equinous Deformity (Talipes Equinus)

PRONATION: ____ of the heel, ____ of the forefoot, ____ of the tibia in relation to the foot, _____ of the sub-talar, and mid-tarsal joints -resulting in a decrease in the medial longitudinal arch. -The foot is much more mobile in this position.

Eversion of the heel, abduction of the forefoot, medial rotation of the tibia in relation to the foot, dorsiflexion of the sub-talar, and mid-tarsal joints

Intra-capsular vs. Extra-capsular swelling can be assessed by looking at the swelling around the Achilles tendon. Extra-capsular swelling = _____ whereas intra-capsular swelling= _____

Extra-capsular swelling is indicated by swelling on only one side of the Achilles tendon, whereas intra-capsular swelling is indicated by swelling on both sides.

DIAGNOSIS: The patient will complain of pain on the lateral aspect of the ankle and have associated swelling. Examination will confirm localized point tenderness and possible crepitus. Selective tissue tension testing is positive Imaging: MRI is helpful in detecting fluid swelling around the tendon and tears within it.

Fibularis Tendon Pathology - Tendonitis

DIAGNOSIS: The patient will usually complain of posteromedial ankle pain which may radiate along the medial border of the foot. Occasionally triggering of the toe may occur. Point tenderness behind and below the medial malleolus. Selective tissue tension testing is positive.

Flexor Hallucis Longus Tendonitis

This structural mid-tarsal deviation involves eversion of the forefoot on the hindfoot when the sub-talar joint is in the neutral position. -With this deformity, during the weight bearing phase of gait, the mid-tarsal joint is supinated so that the lateral aspect of the foot is brought into contact with the ground. -Similar to hindfoot valgus, it contributes to decreasing the medial longitudinal arch and therefore resembles a planus foot type.

Forefoot Valgus

This structural mid-tarsal joint deviation involves inversion of the forefoot on the hindfoot when the sub-talar joint is in the neutral position. -This deformity also contributes to decreasing the medial longitudinal arch and also resembles a planus foot type. -During the weight bearing phase of gait, the mid-tarsal joint is completely pronated in an attempt to bring the first metatarsal head in contact with the ground.

Forefoot Varus

This is condition in which dorsiflexion or extension of the big toe is limited because of OA of the 1st MTP joint. This can also be caused by an anatomic abnormality of the foot. -An excessively long first metatarsal bone.

Hallux Rigidus

A medial deviation of the head of the first metatarsal bone in relation to the center of the body.

Hallux Valgus (Bunion) o The cause of hallux valgus is varied. It may be hereditary and is often familial. -Women tend to get it more than men. (Trying to keep up with fashion may be the cause of this secondary to tight or pointed shoes.) o A callus develops over the medial side of the head of the metatarsal bone, and the bursa becomes thickened and inflamed. -One common factor is over-pronation. -Hypermobility can contribute to the problem

An extension contracture of the MTP joint and flexion contracture at the proximal IP joint - the distal IP joint may be flexed, straight, or hyperextended.

Hammer Toes

This structural deformity involves eversion of the calcaneous when the sub-talar joint is in the neutral position. -The hindfoot is mobile, which may lead to excessive pronation and limited supination. -This may contribute to the appearance of a pes planus foot, with the medial longitudinal arch appearing flattened.

Hindfoot valgus (Rearfoot valgus) NOTE: Because of the increased mobility, it is less likely to cause problems than hindfoot varus.

This structural deviation involves inversion of the calcaneous when the sub-talar joint is in the neutral position. -It may contribute to the appearance of a pes cavus foot, making the medial longitudinal arch appear accentuated.

Hindfoot varus (Rearfoot varus) (more likely to cause problems than hindfoot valgus b/c of decreased mobility)

DIAGNOSIS: -The patient presents with anterior pain with activity and may notice limitation of movement. -They may also notice that they are unable to jump as high or run pain free. -Examination reveals tenderness on the anterior aspect of the ankle. -Dorsiflexion of the ankle on weight-bearing (squatting & stair climbing) will usually cause pain. Imaging is usually positive.

Impingement

Often referred to as "footballer's ankle". Commonly seen in activities requiring forced dorsiflexion -Soccer, ballet Osseous/soft tissue impingement between tibia and talus Due to the formation of bony traction spurs of either the lower border of the tibia or upper neck of the talus. Localized cyclic loading causes stress fracture or exostosis Repetitive forced dorsiflexion

Impingement

FOREFOOT-HEEL ALIGNMENT

In the supine position, place the subtalar joint into the neutral position. While maintaining this position, pronate the mid-tarsal joint maximally and then observe the relation between the vertical axis of the heel and the plane of the second through 4th metatarsal heads. -Normally, the plane is perpendicular to the vertical axis. -If the medial side of the foot is raised, the patient has a forefoot varus. -If the lateral side of the foot is raised, the patient has a forefoot valgus.

____ is the single most common injury seen in athletics

Inversion injury of the ankle with subsequent sprain of the lateral ligaments

SUPINATION: ____ of the heel, ____ of the forefoot, _____ of the sub-talar joint and mid-tarsal joints -so that the medial longitudinal arch is accentuated. -Gives rigidity to the foot.

Inversion of the heel, adduction of the forefoot, plantarflexion of the sub-talar joint and mid-tarsal joints

A fracture of the 5th metatarsal shaft about 1.5 cm from the base is called a ____

Jones fracture -This fracture often occurs with a severe inversion ankle sprain or by a direct trauma. -Radiographs also demonstrate that these are associated with chronic stress. -It has a history of poor reduction or non-union. -Anatomic studies have revealed that this region is relatively hypovascular - leading to delayed healing. -If recognized early there is a much better prognosis.

History and Physical Examination Diastasis: separation of the mortise

Latent: -No widening of the mortise is noted with radiograph but when ER or abduction stress is applied widening occurs greater than 1 mm. Frank: -Mortise widening is easily seen on x- ray -Requires anatomical reduction ****It must be remembered that an syndesmosis sprain may be also accompanied by a fracture of the fibula near the knee! "Maisonneuve Injury"

Longitudinal force applied to a plantarflexed ankle and foot. Observation: -Widening of midfoot -Inability to bear weight -Swelling on dorsum of foot -Palpation 1st and 2nd TMT jt and medial cuneiform

Lisfranc Fracture -Lisfranc ligament is a large band of tissue that spans from the medial cuneiform to the base of the 2nd metatarsal

____ is becoming a reliable imaging technique to distinguish between periosteal edema and frank stress fracture

MRI

The only way to accurately diagnose CECS is by...

Measuring individual intra-compartmental pressures -A catheter is inserted into the appropriate compartment and is then attached to a pressure transducer. -The patient is then asked to exercise the leg in order to reproduce the pain. (pressure is being recorded) -At rest pre-exercise pressure > 15 mm Hg -At 1-minute post exercise pressure >30 mm Hg -At 5-minute post exercise pressure > 20mm Hg -During exercise, the compartment pressure will rise, then return to normal following the cessation of the activity.

Lateral ankle sprain vs. syndesmotic differential diagnosis

Mechanism of injury! Syndesmosis sprains -Most involve an external rotation force as opposed to the inversion force seen with ankle sprains. -The amount of trauma required is much greater, and frequently there will be some associated anterior deltoid ligament tenderness. -The pain may radiate up the anterior leg in a pattern corresponding to the superior continuation of the syndesmosis ligaments (interosseous membrane)

A better name for shin splints:

Medial tibial stress syndrome (MTSS) -usually pain in the lower 1/3rd of the tibia

-the second toe is longer than the first. -Increased stress is put on the longer toe, and the big toe tends to be hypomobile.

Morton's Foot

During _____ chain motion, the talus is considered fixed.

Open During closed chain motion, the talus moves to help the foot and leg adapt to the terrain.

Medial Tibial Stress Syndrome (shin splints) is a _____ that usually occurs at the posteromedial border of the tibia (The differentiation between this condition and a stress fracture is a bone scan. Diffuse tenderness vs. focal tenderness with stress fx)

Periostitis (The differentiation between this condition and a stress fracture is a bone scan. Diffuse tenderness vs. focal tenderness with stress fx)

-This structural deformity occurs when the first ray lies lower than the other four metatarsal bones, so that the forefoot is everted when the metatarsal bones are aligned. -This can contribute to the same conditions seen with forefoot valgus.

Plantar Flexed First Ray

_____________ has been shown to be helpful in tibial stress fracture management. -Return to activity is significantly quicker. The brace compresses the soft tissues in order to increase hydrostatic pressure, which results in shifting of fluid from the capillary space to the interstitial space, thus, theoretically, this enhances the piezoelectric effect and stimulates osteoblastic bone formation.

Pneumatic leg bracing

Treatment for Grade I/II Lateral Ankle Sprain

ROM: -Begin gentle active ROM as tolerated -Begin passive Dorsiflexion in weight bearing and non-weight bearing for gastrocnemius and soleus -Stretch inversion as comfort allows after 3 weeks **Accelerated rehab and early mobility has been proven safe and more effective than traditional PT or immobilization -Still have to protect lateral structures (Focus on DF and EV mobility) Strengthening: -Isometrics all directions -Manual resistance -PRE's all directions with tubing, ankle weights, ankle machines as tolerated -Heel-Toe lifts (Bilateral to Unilateral) -Bike, Leg Press -Pool Functional Progression based upon: (1) ROM (2) Strength (3) Stability (4) Performance--3C's! *Carriage, Control, Confidence

-This is a traction apophysitis of the Achilles tendon attachment to the calcaneous. -The calcaneal apophysis serves as the attachment for the Achilles tendon superiorly and for the plantar fascia and short muscle of the sole of the foot. -Have to have an open growth plate for apophysitis! (so not seen in adults!)

Sever's Disease

Ankle fracture/dislocation Treatment:

Stage 1: Early healing that requires non-weight bearing or modified weight bearing for 6-8 weeks. Stage 2: Continued immobilization but with weight bearing for a similar period (6-8 weeks). Stage 3: Period of rehabilitation. -Once bony stability and alignment is assured, attention may turn to the essential treatment of the soft tissues. -Minimum of 4 months before return to ADL!

-Cumulative effect of chronic microtrauma in bone tissue -Whenever the osteoclast activity exceeds the osteoblast activity small cracks can form in the osseous tissue

Stress Fractures -Rate of loading is the most important factor (vs. the overall magnitude of load)

Localized pain is the main symptom and is usually insidious in onset. -Initially the pain is only felt after activity, but with ongoing impact activity, it becomes more severe and begins to occur during activity. -Eventually, pain progresses until it is present during rest periods (including at night).

Stress reactions/fractures Radiographs are not helpful in the early stages of injury as stress fractures may take several weeks to become evident on radiography. -With healing, the development of a periosteal reaction and medullary sclerosis may appear as a transverse linear line line on radiographs.

____ injuries are more common than lateral ankle sprains in collision sports and those that involve rigid immobilization of the ankle in a boot, such as skiing or hockey. -NOT specifically associated with shoe-type, player position, or field surface

Syndesmotic injuries

Fick angle

The foot assumes a slight toe-out position in standing. This angle (the Fick angle) is approximately 12 to 18 degrees from the sagittal axis of the body.

LEG-HEEL ALIGNMENT:

The patient lies in the prone position with the foot over the end of the table. -Place a mark over the midline of the calcaneous at the insertion of the Achilles tendon. Make a second mark 1cm distal to the first mark. o Join the two marks - calcaneal line. -Place two marks on the lower 1/3rd of leg in the midline. o Join the two marks - tibial line. -Place the subtalar joint in neutral and observe the two lines. They should be parallel to each other. o If the heel is inverted, the patient has hindfoot varus, if the heel is everted - hindfoot valgus.

An ankle x-ray series is only required if:

There is any pain in the malleolar zone & any of these findings: 1) Bone tenderness at the posterior edge/tip of the lateral malleolus 2) Bone tenderness at the posterior edge/tip of the medial malleolus 3) Inability to bear weight both immediately & in ED

A foot x-ray series is only required if:

There is any pain in the midfoot zone & any of these findings: 1) Bone tenderness at the base of the 5th Metatarsal 2) Bone tenderness at the Navicular 3) Inability to bear weight both immediately & in ED

___ is an important stabilizer of the medial longitudinal arch.

Tibialis posterior -Injuries to this muscle may occur with activities producing foot eversion / over- pronation.

DIAGNOSIS: Patient will complain of posteromedial ankle pain that may radiate along the course of the tendon on the medial aspect of the foot.

Tibialis posterior tendonitis

This is a hyper-extension injury combined with compressive loading to the MTP joint of the 1st toe.

Turf Toe

Mechanism of the chronic compartment syndrome

Unknown. -The volume of the exercising muscle may increase by as much as 20% of its resting size during exertion. -Volume expansion with non-compliant fascial and osseous boundaries leads to an increase in the pressure within the compartment. -After a certain pressure threshold, the blood flow becomes insufficient for the metabolic requirements of the muscle - pain ensues (result of muscle ischemia) -Patients will continue to experience pain until the intra-compartment pressure decreases to the level in which the blood flow can again meet the physiologic demands. -It is possible that overuse activity may produce an inflammatory response, leading to a fibrotic reaction.

Testing for tibial torsion; seated method

With the knees flexed over the edge of the table at 90 degrees, place the thumb of one hand over the apex of one malleolus and the index finger over the apex of the other malleolus. -Visualize the axes of the knee and of the ankle. The lines are not normally parallel, but instead form an angle of 12-18 degrees.

Ankle fracture/dislocation tends to occur by ....

a twisting effect of the tibia against a foot that is fixed on the ground (The position of the foot at the time of the twisting force decides the pattern of the fracture)

Retrocalcaneal bursitis is a distinct entity denoted by pain that is ___ to the Achilles tendon.

anterior -The bursa becomes inflammed, hypertrophied, and adherent to the underlying tendon. Results in deep pain and visible swelling. -Bursa are highly vascular

-Displaced fractures of the calcaneus can be a devastating injury. -There can be permanent subtalar stiffness, some chronic arthritic pain, and some substantial loss of ADL function. -The reason for this is that the fracture line extends into the joint resulting in damage and disruption of the ___.

articular cartilage

The most common of all foot injuries

avulsion fracture of the base of the 5th MT

Fibularis Brevis inserts on the...

base of 5th

Be sure to examine the patient's shoes! With a normal foot, the greatest wear on the shoe should be...

beneath the ball of the foot and slightly to the lateral side of the posterolateral heel

The most common form of compartment syndrome seen is the ___ syndrome.

chronic syndrome (rather than the acute)

The majority of tibial fractures occur from a ....

direct blow to the tibia

Athletes with a ____ alignment are more likely to have their ankles in an externally rotated position when planted.

flat foot

Excessive bulging on the lateral side suggests an...

inverted foot

When testing for tibial torsion, remember that some ___ is normally present

lateral torsion (between 13 to 18 degrees).

Syndesmosis tests:

o Wedge test o Squeeze test o External rotation stress test o Inferior Tibiofibular ligament test

The ____ is a separate ossicle at the back of the talus. This usually fuses with the rest of the talus. -usually asymptomatic but posterior ankle pain may occur acutely following a fracture of the posterior tubercle or following an injury to the fibrous union

os trigonum

-Posterior impingement is another cause of ankle pain deep to the Achilles tendon at the posterior aspect of the talus. - It is usually due to impingement of the posterior tubercle of the talus between the ___ & ___. -It occurs as an over-use injury in activities that demand repetitive plantarflexion of the ankle. Also with forced plantarflexion (ie. Kicking)

posterior tibia and calcaneous

Bunionette (Tailor's Bunion) is often associated with a ___ foot

pronated

Activities that involve ___ are also likely to increase the risk of Retro-calcaneal Bursitis

repetitive end-range ankle dorsiflexion

Compression through the ____ helps limit problematic swelling

sinus tarsi (horseshoe; tunnel between the talus and the calcaneus that contains structures that contribute to the stability of the ankle and to its proprioception; subtalar joint)

Tendons, in general, have a low metabolic rate which results in...

slow healing after injuries

The criteria for surgical versus non-surgical management of the ankle are based on these two factors: (because the ankle joint has a low tolerance to changes in its anatomy)

stability and alignment (The fundamental principle is that ankle fractures must be carefully assessed radiographically to determine stability and alignment.) Healing with displacements of as little as 2-3mm can produce accelerated post-traumatic degenerative arthritis.

Most common clubfoot congenital deformity

talipes equinovarus (clubfoot= inward & downward)

The term ____ should therefore be used to cover the range of pathologies that affect the Achilles.

tendinopathy

A one-legged toe stand is a good test of ___ function. With normal function, the patient should be able to perform up to 5 repetitions without pain. With each raise, the heel inverts. With tendinopathy, the patient may have difficulty in performing the test due to pain and weakness. With complete rupture, the heel will fail to invert.

tibialis posterior

It appears that the combination of ____ & ____ are the main causes of MTSS.

traction on the periosteum by the calf muscles & repetitive bending loads across the tibia Can involve Soleus, BUT ...Flexor Digitorum Longus, and / or Tibialis Posterior is also common

The acute compartment syndrome is usually the result of ___

trauma such as with a fracture. -A rapid compartment volume increase occurs due to the arterial bleeding associated with the fracture. -In this case, an immediate fasciotomy is required - SURGERY!!!

Excessive bulging on the medial side of the shoe suggests a ...

valgus or everted foot

Critical compartment ischemia occurs when the compartment pressure increases to ...

within 20 mm Hg of the diastolic pressure