Ankle and Foot

How do Achilles tendon injures typically occur?

"Weekend Warriors" episodic athletes: when someone that hardly exercises doesn't warm up before doing a forced plantarflexion exercise etc. like playing dodgeball/running Usually occur as a traumatic injury during a sporting activity: sudden forced plantar flexion or violent dorsiflexion in a plantarflexed foot. "somebody kicked me in the back of the leg" or "somebody shot me!"

What are important things to evaluate on physical exam of Hallux Valgus?

**Physical features: -hallux rests in valgus and pronated -Big toe sometimes goes over or under the second toe -will see a bump on the side of the big toe and redness due to the medial eminence irritation Evaluate associated deformities: -Pes planus (flat foot) -Lesser toe deformities -Midfoot and hindfoot conditions -Corns, calluses, interdigital neuromas, bunionettes, hammer toes and claw toes -generalized ligamentous laxity

Why would we get in MRI for an ankle exam?

**rarely useful acutely: if they had an injury, they will have edema in the area and that is what an MRI would show you (which you already know, so not really useful) -won't likely change the treatment in any way When it is useful: *if you are concerned about other injuries -Osteochondral injury or tendon injury is suspected -will show ligament injury -may be indicated if pain persists after 8 weeks of appropriate treatment

What typically causes fractures of the phalanges?

Trauma

ATFL has the --- threshold for failure

lowest

What are the risk factors for plantar fasciitis?

-High BMI -long hours standing on hard surfaces -Pes planus (flat foot) or cavus (high arch) -Achilles contracture: our foot is supposed to dorsiflex, if your achilles is too tight, there will be extra stress on the foot. A contracture is a condition in which a tendon or tendon sheath stiffens and becomes permanently tight, limiting flexibility and joint movement.

What are the signs and symptoms of Hallux Rigididus?

-Painful, reduced motion through the first MTP joint: especially during the toe-off phase of gait -Bony prominence dorsally: often tender due to rubbing on shoes

Which metatarsal is more likely to have a stress fracture?

2nd metatarsal because it is the longest

What toe is most commonly affected in metatarsalgia?

2nd toe (longest in many people)

Why are X-rays useful in Hallux Valgus?

-need to make assessments of bones to see if we can fix the bone and how we are going to fix it. There could be: -displacement of sesamoids: often disrupted laterally -joint congruency

What are the signs and symptoms of an ankle sprain?

-present with pain and tenderness usually over the lateral ankle, occasionally over the medial -may have pain with weight bearing -Often have bruising or swelling over the lateral ankle, may extend into the foot

What is the nonoperative treatment of Achilles tendon injury?

-serial casting tries to bring ends of Achilles together.. what it is-bracing in maximal plantarflexion with progressive return to neutral (patient comes back almost every week and slowly have casting move from maximal plantarflexion to neutral)

Radiology of Achilles tendon injury

-standard ankle x-rays rule out associated injury -MRI is only necessary if the physical exam is equivocal: rule out partial tear, gastrocsoleus injury, or plantaris rupture -Ultrasound: not recommended However, potentially going to be first line very soon because can often see the rupture and distinguish partial versus complete, and assess the amount of distraction

What are the different types of fifth metatarsal base fractures?

1. Avulsion fractures of the tuberosity (extraarticular, PB tendon or lateral band of PF) 2. Intraarticular (most common) 3. Jones fractures Can also have shaft fractures distal to the proximal third

What is a high ankle sprain?

A sprain of the syndesmotic ligaments between the tibia and fibula Less than 10% of sprains Take longer to heal -------------------------------------- FYI: (syndesmotic ligament keeps bones from moving apart, so that your ankle doesn't move around as much) if you invert the foot.. this can happen. FYI: Typically see in football players

What is a trimal equivalent?

A trimalleolar fracture can be trimal equivalent if lateral and posterior fracture seen with lateral translation of the talus in the ankle mortise (see 2 fractures, but acting like there is 3)

What is the largest tendon in the body

Achilles tendon

What is a trimalleolar ankle fracture?

Actual fracture of all three (lateral, medial and posterior)

What are the different types of Hallux Valgus?

Adult and Adolescent and juvenile types (usually wait until skeletal maturity to fix juvenile)

What are Achilles tendon injuries often misdiagnosed as?

An ankle sprain -up to 25% are missed -high index of suspicion should be maintained

If a patient has chronic instability of the ankle, we would refer for possible

Ankle ligament reconstruction: -modified brostrum repair -possible excision of nonunited avulsion

Injury to the ligaments that stabilize the ankle

Ankle sprain

What may impingement of the ankle need for treatment?

Arthroscopy

What is a plantaris tendon rupture?

Plantaris muscle is a small muscle that runs behind knee and attaches to calcaneus. It has a very thin tendon. Not used in humans, but if it ruptures, it acts like Achilles tendon rupture. Some kind of bulge or other finding in the gastrocsolues complex.

Why are Jones fractures much more likely to produce a delayed union or nonunion?

Because of the vascular anatomy of the area (little blood supply of the area) -occur in a vascular "watershed" area

What can forefoot pain (metatarsalgia) lead to?

Can lead to weakening and rupture of the MTP joint capsules including the plantar plate, resulting in medial or lateral deviation or clawing of the toes

What are the different ranges of a "sprain"

Can range from stretching and partial tearing to complete tears Most often occur as a result of a twisting injury of the ankle

What typically causes Morton's neuroma?

Characterized by perineural fibrosis (scar tissue around nerves) and entrapment of the interdigital nerve, probably due to repetitive microtrauma

What typically leads to the inflammation in plantar fasciitis?

Chronic overuse--> microtears: -recurrent trauma produces chronic inflammation and periostitis (inflammation of the periosteum) Your plantar fascia is in the shape of a bowstring, supporting the arch of your foot and absorbing shock when you walk. If tension and stress on this bowstring become too great, small tears can occur in the fascia. Repeated stretching and tearing can irritate or inflame the fascia -usually a low grade, simmering inflammation that does not cause it to rupture, but often doesn't heal for months or years without proper treatment

What is the weber classification?

Classification for fractures of the ankle Weber A Weber B Weber C

The least likely ligament to be injured in the ankle

Posterior talofibular ligament (PTFL)

What is provocative testing in Morton's neuroma?

Compression of the webspace while compressing the metatarsal heads together: Finger on top of foot and thumb on bottom of foot and pinch between the 3rd and 4th metatarsal heads. At same time with other hand, squeeze the 3rd and 4th metatarsal heads together. positive test: Mulder's click-palpable click and pop with lateral compression of the metatarsals with REPRODUCTION OF SYMPTOMS (numbness etc)

Treatment for Hallux Rigidus?

Conservative: -stiffer shoes -forefoot shank (piece of fiberglass that goes under foot in shoe that prevents foot from bending-just helps with the pain) Typically leads to needing surgery: -surgical debridement of the spurs: usually involves removal of dorsal 1st MT head as well

A robust ligament with a broad surface conferring with a high tensile (tension) strength

Posterior talofibular ligament (PTFL) -strongest of the three ligaments

What degeneration is common in Hallux Valgus that sound be noted on X-ray?

Presence of first MTP joint and first metatarso-cuneiform joint will have degenerative changes

What should be included in physical exam of Metatarsalgia?

Dorsal drawer testing of MTP joints to check for instability of joint Palpate under the metatarsal heads: reproduction of pain more indicates metatarsalgia than Morton's neuroma Discrete vs. diffuse callus formation (specific pain under their 2nd metatarsal head and a callus in the area)

Treatment for stress fractures of metatarsals

Treat with CAM boot or post-op shoe F/U xrays in 2 weeks to look for bony callus (want to see healing of the bone)

Due to the biomechanics of the foot/ankle, what motion is most common that causes ATFL injury? Why?

Due to the biomechanics of the foot/ankle, inversion/plantarflexion injury is the most common Why: energy moves in line with the ATFL-if the front of the foot goes straight down, this ligament is pointed straight down and is what typically leads to a tear.

How will a patient present if an Achilles tendon injury?

Present with pain in the heel/posterior lower leg Weakness in the ankle: may have difficulty walking, climbing stairs Will have a limp: Gait abnormality may be a lot more subtle than you expect

What is Hallux Rigididus

Exostoses (extra growth of bone-develop spurs on MTP joint) involving the 1st MTP joint d/t: -arthritis: most common type in the foot -trauma -overuse

How will a patient present if a stress fracture to the 2nd metatarsal?

Present with progressive pain with activities May not see fracture initially, or ever -must have a high index of suspicion

What can Hallux Rigidus be associated with

Hallux valgus

What are associated conditions of Hallux Valgus?

Hammer toe, calluses

T/F Plantar Fasciitis can take months to fully resolve even with effective treatment

True

What is the treatment for Achilles tendon injury?

If a rupture is diagnosed (or even suspected)-REFER THEM, and the sooner the better: -outcomes are much better if caught early, and may be severely compromised after 6 weeks Can be treated operatively or nonoperatively

What is treatment for a medial ankle fracture?

If fracture is below the tibial plafond with minimal displacement of the fragment, may be able to treat conservatively with casting Typically best to refer to ortho as there is a high chance of syndesmotic injury

Treatment for Weber A fracture?

If fragment is minimally displaced, can treat with casting Screw fixation is sometimes necessary

T/F The vast majority of ankle sprains heal without sequelae, but they can result in chronic instability of the ankle

True

Treatment of fracture to the phalanges?

If no deformity: buddy taping 4-6 weeks until healed (tape one toe to the other) If deformity is present, consider digital block with reduction -pre and post reduction films required

What is a bimalleolar fracture of the ankle?

Two malleoli (typically medial and lateral)

What are the differential diagnoses of plantar fasciitis?

DDX includes heel pad atrophy, stress fractures of the calcaneus, tarsal tunnel syndrome (medial calcaneal branch), Achilles insertional tendonitis, contusion, Sever's apophysitis in teens, inflammatory arthritides (enthesopathy)

What should you NOT do for plantar fasciitis treatment and why?

DON'T do steroid injections: -painful and don't usually give lasting relief -can make the fascia rupture! Weakens the plantar fascia -not effective for healing: inflammation is how connective tissue heals

An osteochondral injury (OCD) is another injury you want to rule out when a patient has an ankle sprain. What is an osteochondral injury?

Damage to the joint surface of the talar dome at the time of the injury FYI: when foot inverts, the medial corner of talar dome bangs up against the medial mallelous and crushes it-developing an area of "dead bone"

What will physical exam show of Hallux Rigidus?

Decreased ROM through the 1st MTPJ: -active and passive dorsiflexion -usually painful to dorsiflexion Palpable spurring around joint line: especially dorsally

What are the signs and symptoms of Hallux Valgus?

Difficulty with shoe wear due to medial eminence- the medial aspect of first MTP joint becomes very painful and rubs on their shoes (most common symptom) Pain over prominence at MTP joint Cosmetic concerns Pain underneath the second metatarsal head (as the deformity develops, it changes the weight bearing pressures of the foot) Compression of digital nerve may cause symptoms

Peroneal tendon injuries also need to be ruled out when a patient an ankle sprain. Where will the patient feel pain on physical exam if there is a peroneal tendon injury?

FYI: Peroneal is on the lateral side of the ankle (2 of them that run behind the lateral malleolus) The function is to keep the foot from inverting, so when our foot inverts real hard during a sprain, the tendons pull real hard to try and correct the foot which causes a tear 1. pain to palpation over tendons 2. pain with stressing of tendons (have evert foot against pressure to test the peroneal tendons)

Why is fracture of the lateral process of the talus called a snowboarder's fracture?

FYI: boot bindings-ankle does not invert how it should because the boots keep the foot locked in, so you get inversion in a different plane which causes a fracture -see more in notes for x-ray examples -this fracture requires surgery

T/F Heel spur can cause plantar fasciitis

False

Which gender is more affected in Morton's neuroma?

Females

Which metatarsals may be fractured in ankle sprains?

Fifth metatarsal fractures, especially avulsions (same mechanism: plantarflexion, inversion injury can fracture because the peroneal tendon pulls on it very hard) Physical exam: make sure to palpate down along the fifth metatarsal to make sure there is no pain through midfoot joints/pain with motion

What is the management of Hallux Valgus?

First line treatment: -bunion splints -shoe modification/pads/orthoses -exercises, and activity adjustments -orthoses more helpful in patients with pes planus or metatarsalgia

What medications can predispose people to Achilles tendon rupture?

Fluoroquinolones and steroid injections can predispose

What is metatarsalgia?

Forefoot pain/ball of foot becomes painful and inflammed (pain under the metatarsals)

What is a Weber B fracture?

Fracture begins at the talar dome and continues obliquely proximally

What is a Weber C fracture?

Fracture is above the talar dome -inherently unstable due to syndesmotic ligament disruption

What is a Weber A fracture?

Fracture is below the talar dome

What are the intrinsic risk factors of Hallux Valgus?

Genetic predisposition, ligamentous laxity Convex metatarsal head Pes planus RA Cerebral palsy

What is the squeeze test?

Go halfway up the leg, squeeze the fibula into the tibia. If there is pain at the ankle, you have high index of suspicion for a syndesmosis injury (high ankle sprain) REFER!!

What should you consider if the two tests for Achilles tendon injury are negative?

If these two tests are negative: -patient may still have a partial tendon tear or strain, or gastrocsolues muscle tear -plantaris tendon rupture can mimic an Achilles injury

What is morton's neuroma?

Inflammation of one of the interdigital nerve branches usually at the 3rd interspace (between 3rd and 4th MT heads) Can also affect the 2nd webspace Morton's neuroma typically presents with compressive neuropathy: patient will feel numbness or tingling of the toes

What is the treatment for an ankle sprain?

Initially: -RICE (rest, ice, compression, elevation) If severe: -1-2 weeks of weight bearing immobilization in a CAM boot or walking cast -early mobilization is helpful Bracing: -best are the lace up that don't have metal or plastic support.. better than stirrup Later: -Physical therapy after pain subsides -ROM strengthening (especially peroneal), proprioceptive retraining (brain's ability to know what body is doing-protective sensation.. for example, when you step on a rock and it hurts this is proprioceptive function. This is VERY important) -Early functional rehab leads to best results

What are important things to do in the physical exam of an ankle sprain?

Inspect for bruising and swelling Assess weight bearing -if the patient can walk: in fracture, they cannot bear weight.. so this would be a good sign. Would lead you down path to sprain instead of fracture. Palpate the ligaments, look for tenderness Palpate the peroneal tendons and stress them if able Palpate the 5th metatarsal base Syndesmosis: squeeze test know this!! **test question**see next flashcard Watch for associated injuries: -Malleolus fractures, especially avulsion fractures (small chunk of bone will be pulled away from the main part of the bone) medial malleolus fractures with an inverted injury of the foot, the talus bangs up against the medial malleolus which causes a fracture.

What does the posterior talofibular ligament resist?

Inversion and external rotation

What is a Jones fracture?

Involves the proximal third of the 5th metatarsal, but NOT the joint space.

What is Hallux Valgus?

Lateral deviation of great toe with medial deviation of first metatarsal Often accompanied by deformities of lesser toes

In fractures of the ankle, what are the different single malleolus that are involved and which is most common?

Lateral-most common Medial Posterior-uncommon

What are the long term effects of surgery for Morton's Neuroma

Leave permanent numbness of webspace. SHOULD NOT be done to adjacent webspaces

What are the consequences of achilles contracture that leads to plantar fasciitis

Loads facia earlier in the gait cycle Increases plantarflexion force during gait cycle Stresses fascia

Differential diagnosis of Morton's Neuroma

MTP synovitis Metatarsalgia Stress fracture MTPJ arthritis Metatarsal head osteonecrosis Neoplasm Lumbar radiculopathy

Who may nonoperative treatment of Achilles tendon injury be preferred in?

May be preferred for medically frail or sedentary patients This is considered/used by a lot of orthopedics: -fewer wound and nerve complications -however, higher rate of rerupture? -technically difficult to do right

Which gender are Achilles tendon injuries more common in? What age?

Men 30-40

Which is more common: Morton's neuroma or metatarsalgia?

Metatarsalgia -morton's neuroma is much less common than other sources of foot pain

Not all forefoot pain is ---

Morton's Neuroma

Generally, ankle sprains occur from --- and --- of the foot

Plantarflexion and inversion of the foot Example: stepping into a hole-front part of foot falls into the hole as you fall down, foot turns inside.. Also stepping off a curb etc.

In surgery for Morton's Neuroma, if large neuroma is encountered, what typically happens

Neuroma is excised

What are the physical exam components of Morton's neuroma?

Neuroma may be palpable in the webspace, deep to the transverse metatarsal ligament Provocative testing

Treatment of Jones fractures?

Nonoperative treatment • Only appropriate for completely nondisplaced fractures in low-demand patients. • NWB SLC for a minimum of 6-8 weeks • Watch very carefully for signs of healing versus sclerosis of fracture edges or displacement. 90%+ need operative screw fixation • Especially athletes, displaced fractures, or stress fractures. If in doubt, REFER.

When would labs be useful for plantar fasciitis?

Only useful if other diagnoses considered such as RA

What is the surgical treatment of Achilles tendon injury? Pros and cons?

Open repair or percutaneous Higher incidence of wound complications and sural nerve injury Lower rate of re-rupture? More reliable outcome

What are associated injuries with an ankle sprain you should be aware of?

Osteochondral injuries (OCD) Peroneal tendon injuries Fifth metatarsal fractures-especially avulsions Fractures of the posterior malleolus Fractures of the anterior process of the calcaneus (near cuboid) Fractures of the lateral process of the talus (snowboarder's fracture)

What is the most common cause of forefoot pain (metatarsalgia)

Overwork of the foot/mechanical overload that results in capsulitis (see pic: Capsulitis is an overuse injury that affects the ligaments around the joint where a metatarsal meets a toe in the ball of the foot) -Patients that have this mechanical overload are typically predisposed by tight Achilles, cavus foot, age-related fat pad atrophy, prolonged standing on hard surfaces, toe deformities, poor shoe wear (HIGH HEELS!)

What are the signs and symptoms of Morton's neuroma?

Pain and paresthesia in affected toes and also the plantar aspect of the webspace "wrinkle in my sock" Usually worse with weight bearing and tight or high heeled shoes May be relieved by removing the shoes and massaging the foot

How will a patient present if fracture to the phalages?

Pain, bruising

Radiology for plantar fasciitis?

Plain films not usually needed unless you suspect other pathology Standing films may be useful to assess alignment for pes cavus or planus MRI and bone scan will show the inflammation, but don't really have a role in routine evaluation and treatment

Plantar fasciitis is caused by --- of the fascia, usually at its origin from the ----

Plantar fasciitis is caused by inflammation of the fascia, usually at its origin from the calcaneus

If the Achilles tendon is completely ruptured, the patient can still actively ----

Plantarflex the foot -they may walk with a limp, but it may be very subtle. They still have active plantarflexion. -FYI: big mistake in primary care is assuming they cannot plantarflex the foot! Lots of people miss this

What are the Ottawa ankle rules?

Reasons you would need to get an x-ray: -inability to bear weight (cannot walk) -medial or lateral malleolus point tenderness (bone pain) -5th metatarsal base tenderness -navicular tenderness (midfoot tenderness-movement OR palpation through the midpoint)

What should you do if ankle sprain is not better in 8 weeks?

Refer -may have subtle undiagnosed injuries -may have chronic instability (particularly repeat ankle sprains run higher risk of developing chronic instability where the ligaments become incompetent which leads to chronic repeat injuries)

What is the treatment for a Weber C fracture?

Requires surgical fixation with syndesmotic screw placement

DON'T INJECT --- NEAR OR AROUND THE ACHILLES

STEROIDS

What may high ankle sprains require for treatment?

Screw fixation or repair

What are the extrinsic risk factors of Hallux Valgus?

Shoes with high heel Shoes with narrow toe box

Treatment for forefoot pain (metatarsalgia)?

Shoewear/activity modifications: -avoid high heels and poorly padded shoes -metatarsal pad orthotics are the main treatment Achilles stretching or possible lengthening Corrective insoles or surgery for cavovarus foot Surgical correction of deformities: hallux valgus, clawed toe, weil or dorsal wedge osteotomy of the metatarsal head to relieve pressure

Small avulsion fractures of the malleolus usually will --- and are treated like ---.

Small avulsion fractures of the malleolus usually will heal and are basically treated the same way (as a ankle sprain and not a true fracture)

What will X-rays show of Hallux Rigidus?

Spurring around the joint (smooth, hard bumps that form)

What is the function of the Achilles tendon?

Stores elastic energy during gait cycle, jumping and running

What is the treatment for plantar fasciitis (the first choice treatments)

Stretching, both fascia and achilles: First thing in the morning before arising and 5-6 times per day Night splint: keep achilles stretched and prevent shortening of fascia overnight Ice massage 2-3 times daily Orthotics: -Arch support with heel padding helpful -Consider a moldable heel cup (seen in pic-customary made), especially if heel pad atrophy is contributing (fat pad on heel wears out which can contribute to plantar fasciitis) NSAIDs: -help the pain, don't really heal anything Physical therapy (usually not first recommendation-do this if home exercise does not work) Walking cast immobilization for 4-6 weeks: helps in most cases.. can move things forward to the point where the treatments can work. CAM boots not nearly as effective

How can Morton's Neuroma recur after surgery?

Stump neuromas: A stump neuroma is a result of a detached nerve, which shapes into a stump or ball. It is an abnormal nerve growth

When would we consider surgical treatment for plantar fasciitis? What are the different surgical options?

Surgical treatment is usually reserved as the last resort Plantar fascia partial release (plus release of Baxter's nerve): -usually effective, but can be very unpredictable in how long it will take to recover -usually wait until 6-9 mo of treatment w/o relief -70-90% success rate Gastrocnemius release Shock-wave therapy is controversial: only 30% or less improvement

When is surgery an option for Hallux Valgus?

Symptoms present with secondary deformities and shoe modification fails **DO NOT preform for cosmetic reasons alone

What ligament is injured in eversion injuries of the ankle?

The deltoid ligament (not as common)

What is the dorsal drawer test?

The second toe is grasped between the thumbs and index finger, and the second MTP joint is stressed in a vertical direction. Instability of the joint is demonstrated with increased mobility of the second MTP joint. https://www.youtube.com/watch?v=zUavaVTOHi4 (skip to 1:45)

What are the different views we need to get in x-ray

Three standard views: standing if possible/tolerable **mostly looking for associated injuries: subtle widening of the syndesmosis if suspected-when the ligament between the tibia and fibula is torn, when they stand up, the bones will widen out a little bit

When may an EMG/NCV (nerve conduction velocity test) be useful in plantar fasciitis?

To rule out tarsal tunnel or radiculopathy

Anterior talofibular ligament (ATFL) primarily resists ---- motion of the talus in the sagittal plane

Translational (resists forward motion of the foot)

What should you do in physical exam of plantar fasciitis?

Usually anteromedial plantar heel pain -central or marginal heel pad more often fat pad atrophy Dorsiflexion of toes may worsen pain (not often)

What are the signs and symptoms of plantar fasciitis?

Usually insidious onset, but injury may provoke it Start up pain is the hallmark: first steps out of bed or after prolonged sitting Usually pain is worse by the end of the day

Treatment for Weber B fracture?

Usually is displaced enough to require open reduction with internal fixation (ORIF) If non-displaced in a compliant patient: may elect to treat with casting and NWB -must have a low index of suspicion for syndesmotic ligament injury (no widening on xrays, neg. squeeze test)

What should you do on physical exam of Achilles tendon injury and what will be positive results?

Weakness or pain with resisted plantarflexion of foot Inability to single-stance toe rise Majority will have a palpable defect in the tendon (compare to other side if needed): you can usually feel the injury Tests: 1. Lay the patient prone on the exam table with legs bent at the knees at 90 degrees. -compare the resting position of the two feet -if completely ruptured, the foot will be more dorsiflexed 2. Thompson test. KNOW THIS! squeeze the calf muscles: -foot will move if the tendon is intact -foot will not move or will move minimally if it is ruptured

Treatment of Morton's Neuroma

Wide toe box shoes, metatarsal pad orthotic Steroid injection Surgery: release of intermetatarsal ligament with exploration of webspace

Which gender is Hallux Valgus more common in?

Women

Who does plantar fasciitis affect more?

Women

Radiographs for Hallux Valgus

X-rays: weight bearing AP and lateral -sesamoid view can also be useful

Most commonly injured ligament

anterior talofibular ligament (ATFL)

Small avulsion fractures of the malleolus have a higher probability of --- if they do not heal

chronic ankle instability FYI: avulsion fracture on medial side have a tendency to not heal as well as lateral side

What forms the Achilles tendon?

gastrocnemius and soleus

Most common cause of heel pain

plantar fasciitis