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When is a radiograph warrented following an ankle sprain?
- Pt unable to bear weight immediately after injury or during the exam.
- Bone tenderness is present at any one or more of the following sites; crests or midportion of the lateral or medial malleolus, navicular, or base of the 5th metatarsal.
- Modified Ottawa Rules
What is a Pott fracture?
An avulsion fracture of the medial malleolus. Usually occuring with a deltoid lig sprain.
Describe the typical patient with Sever disease.
An active 6 to 12 yo with complaint of activity-related pain over the posterior aspect of the calcaneus. there is often pain with PROM or AROM into DF and tenderness to compression or palpation over the calcaneal apophysis. Heel walking with be painful.
Describe the management of Sever disease.
Often self-limiting. Gentle calf stretching and activity modification, orthosis, and anti-inflammatory meds help. If PT and pharmacological interventions are not helpful, casting will be utilied for 3 to 4 weeks.
The use of this may help to decrease the stress on the fibularis tendon.
A lateral wedge
This fibulars muscle is more likely to develop a tendinosis.
Fibulars brevis due to the proximity of the tendon to the fibula as it courses near the lateral malleolus.
What is Kohler disease?
Osteonecrosis of the navicular.
What is the typical presentation of Kohler disease?
- More common in boys, often in 5 yo. Girls usually at age 4.
- Commonly a unilateral problem and is characterized by radiographic findings of a flattened, narrowed, sclerotic, and irregular rarefaction of the navicular.
- Typical clinical presentation includes walking with a simp, localized pain and tenderness over the navicular and midfoot, possible swelling, and normal ROM in the talocrural and subtalar joints.
- Posterior tibials testing may be painful
What is the management of Kohler disease?
- Usually self limiting.
- Use of arch supports and activity restriction may be necessary.
- If symptoms persist, a short walking cast will be used for 6 to 12 weeks.
What is a lisfranc injury?
Fracture-dislocations of the LIsfranc joint (tarsometatarsal articulations) and can be the result of direct or indirect trauma.
What is appropriate managent of a Lisfranc injury.
- Immobilization for 6 weeks in a mild to moderate sprain.
- ORIF with 8 to 12 weeks immobilization in more severe injuries.
- PT after immobilization to emphasize edema reduction, strengthening, flexibility, foot orthoses, and gait training.
This has been shown to be very effective in reducing initial strain on the plantar fascia.
What is a tarsal coalition?
A complete or partial union of 2 tarsal bones.
What are the most common sits for tarsal coalitions?
- Between the calcaneus and navicular or between the talus and calcaneus.
- Unions between the talus and navicular may occur but are extremely rare.
What age ranges for different tarsal coalitions?
- Rare talonavicular - 2 - 4 yo
- Calcaneonavicular - 8-12 yo
- Talocalcaneal - 12-14 yo
Describe management of tarsal coalition.
- Conservative management is the primary treatment.
- Activity restrictions
- Casting for 3-6 weeks if pain persists
- Surgical resection is all conservative techniques fail. PT for ROM important after surgical resection.
What type of orthotics or foot wear modifications are appropriate for hallux rigidus?
- First ray cut-out on orthotic
- Rocker-bottom shoes or shoes with metatarsal bars
What are the two surgical procedures for hallux rigidus?
- Cheilectomy prior to arthrodesis
- 50% normal extension ROM with cheilectomy
Are custom foot orthoses helpful in treating hallux valgus?
Yes, when pain, not cosmesis is the primary complaint.
What is metatarsalgia?
- General pain in the forefoot region.
- Typically associated with pain on the plantar surface of the second and third metatarsals but may traverse the entire ball of the foot.
What are the symptoms of metatarsalgia?
- Increased pain with prolonged standing, walking, or with running.
- Pain alleviated with rest.
- Numbness and tingling may be present and may indicate a more specific condition.
- When numbness and tingling is present, a more systemic problem may be indicated, such as peripheral neuropath.
Describe appropriate management of metatarsalgia.
- Reducing pressure on the forefoot, either with arch taping, metatarsal arch supports, or orthoses.
- Flexibility for the calf.
- Inversion strengthening.
- Reduced heel height or increased diameter of the toe box.
Walking with a marble underneath the forefoot is a common complaint with this condition.
Metatarsophalangeal joint synovitis
What joints are most frequently involved in metatarsophalangeal joint synovitis?
Second MTP or the third MTP.
Describe the typical patient presentation with morton neuroma.
Woman between the ages of 25 to 50 yo and typically unilateral.
What is the typical clinical presentation of morton neuroma?
- Reports of an electric shock or burning sensation that usually begins in the second metatarsal interspace, which can travel into the lateral second toes and medial third toe.
- If the third metatarsal interspace is implicated, then pain may travel into the lateral third toes and medial fourth toe.
Describe treatment of a mortans neuroma.
- Metatarsal pads, orthotics, calf strtching, forefoot strengthening, and nerve gliding.
- Inflammatory meds and analgesics.
- Surgical removal of the neuroma may be used in recalcitrant cases.
What type of individual develops sesamoiditis?
- Young, active individuals that engage in activities that require pushing off of the forefoot.
- The sesamoids are located plantar to the 1st metatarsal head and exist to improve the effectiveness of the flexor hallicus brevis tendon.
Describe treatment of sesmoiditis.
- Anti-inflammatory meds
- Dancer's pad or metatarsal pad
- Calf stretching
- Inversion strengthening
- Orthoses to control for excessive pronation
- Cut-out under the sesamoids on the orthosis to reduce pressure
What portions of the lateral ankle ligaments are intra-articular?
The anterior and posterior talofibular ligs.
What are the 4 ligaments of the subtalar joint?
- Cervical ligament - Attaches to the upper surface of the lateral calcaneus and a tubercle on the lateral aspect of the neck of the talus
- Medial talocalcaneal ligament - Attaches to the medial tubercle of the calcaneus and blends with the deltoid ligament
- Lateral talocalcaneal ligament - Attaches from the lateral process of the talus to the lateral surface of the calcaneus just anterior and superior to the calcaneofibular ligament
- Interosseous talocalcaneal ligament - Broad and flat and passes trasversely in the sinus tarsi
What is the convex/concave relationship of the anterior talocalcaneal joint?
Convex talus and a concave calcaneal facet.
True or False
A single joint capsule surrounds the entire talocalcneonavicular joint.
What are the primary restraints of the of the saddle shaped calcaneocuboid joint?
- Bifurcate ligament (lig of Chopart)
- Short and long plantar ligaments
What joints make up the Chpart joint?
What is the Lisfranc joint?
The tarsometatarsal joint
Describe the articulations at the Tarsometatarsal joint.
- First met and medial cuneiform
- Second met and medial, lateral, and middle cuneiform
- Third met and lateral cuneiform
- Fourth met and lateral cuneiform and cuboid
- Fifth met and cuboid
What are the first layer of plantar foot muscles?
- Abductor hallicus
- Flexor digitorum brevis
- Abductor digiti minimi
What are the second layer of plantar foot muscles?
- Deep portion of the quadratus plantae
- 4 lumbricals
What are the third layer of plantar foot muscles?
- Flexor hallicus brevis
- Adductor hallicus
- Flexor digiti minimi
What are the fourth layer of plantar foot muscles?
- 3 plantar interossei
- 4 dorsal interossei
This portion of gait should be the cessation of pronation.
What amount of 1st MTP extension is needed during gait?
What is a norm score for the Timed Up and Go Test?
- 60-69 yo - 8 seconds male and female
- 70-79 yo - 9 seconds male and female
- 80-89 yo - 10 seconds male and 11 seconds female
What is the norm for chair stands in 30 seconds?
- Men 60-94 yo - 14.2
- Women 60-94 - 12.7
What is the norm score on the Berg Balance Scale?
- Men: 60-69 - 55; 70-79 - 54; 80-89 - 53
- Women: 60-69 - 55; 70-79 - 53; 80-89 - 50
What score on the Tinetti balance and gait tests is a high risk of falls?
- Less than 19
- 19-24 = risk for falls
- Out of a possible 28
This type of fracture can occur from forceful plantarlexion and inversion, and may be misdiagnosed as a lateral ankle sprain.
Anterior process of the calcaneus
What percentage of the talus is covered by articular cartilage?
70%, making most fractures intra-articular
This type of talus fracture results from forced dorsiflexion and ER of the foot.
While rare overall, what midfoot fracture occurs most often?
- Navicular tuberosity.
- Management of navicular tuberosity fractures is immobilization of the limb in supination.
What is treatment for a non-displaced fracture of the second through fifth metatarsals?
Tape immobilization and weight bearing as tolerated.
Treatment of a nondisplaced fracture of the first metatarsal?
No weight bearing for 2 weeks followed by progressive weight bearing.
What is the treatment of a middle and distal diaphysis fracture of the 5th metatarsal?
Base of the 5th metatarsal?
- Tape immobilization and weight bearing as tolerated for the middle and distal diaphysis.
- Tape immobilization and weight bearing as tolerated for avulsion fracture of the base.
- A Jones fracture occurs at the proximal diaphysis and is associated with high incidence of delayed union and nonunion.
Where do stress reactions occur on the 1st metatarsal?
2nd and 3rd?
- Medial base of the 1st
- Distal diaphysis of the 2nd and 3rd
- Middle or distal diaphysis 4th
- Junction of the metaphysis and diaphysis 5th
Where does an achilles tendon rupture usually occur?
How long is toe walking consideed a normal activity?
For the first 6 months following initiation of walking, but a typical heel-toe pattern should e evident by 2 years.
Describe the management of idiopathic toe walking.
- If child is less than 3 to 4 yo and has minimal tendon contracture then conservative management is performed. The goal is 10 deg DF. If the isn't reached within 3 to 4 months then serial casting for 6-8 weeks.
- More severe contractures a treated with tendo-Achilles lengthening with casting for 6 weeks.
What is conservative management of clubfoot?
- Manual manipulation of the foot and serial casting for 2-3 months.
- If successful, a foot abduction bar is worn full time fo 2-3 months, then at night and during naps for the following 2-4 years.
Describe surgical intervention of clubfoot.
- Typically between 3-6 months of age, up to 5 years.
- If early, posterior, medial, or lateral soft tissue procedures are the optimal choice.
- If performed in a child 3 years or oler, lateral column shortening is performed in conjuction with soft tissue procedures.