Foot and Ankle

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					                                  Basic Orthopaedics for PA Students
                                            Foot and Ankle
                                     Charles Walker, Ph.D. PA-C
NCCPA Knowledge and Skills Area
for Ankle / Foot
Disorders of the Ankle/Foot
Fractures/dislocations
Sprains/strains



Reading: Essentials, Section Seven with particular attention to the following pages: 406-
419; 422-425; 448-462; 508-510
Netter’s Anatomy, Plates 488A-B; 489 A-B; 491 A-B

                                     Overview of Ankle and Foot

Anatomy of the Ankle and Foot

Bones of the forefoot, midfoot and hindfoot (Netter’s Plates 488A 488B 489A 489B)
     Calcaneus Talus Articulations
     Navicular
     Cuboid
     Cuniforms
     Metatarsals
     Phalanges
Bones of the ankle joint (Netter’s Plates 488A 488B 489A 489B)
     Talus Tibia Fibula Articulations
Ligaments of the ankle (Netter’s Plates 491A 491B)
     Lateral Collateral Ligaments
     Syndesmotic Ligament
     Deltoid Ligaments

                                   Common Clinical Presentations:

Chief Complaint:
     Pain most common cc: of foot.
Chronic pain more common than acute pain.
     Chronic pain > 2 week duration.
     Acute pain < 2 week duration.
     Acute pain  think fracture, sprain, strain or infection
     Acute pain over metatarsals (esp distal portion of 2nd and 3rd) is suggestive of stress fracture

Forefoot problems:
9 times more likely in women than men  high heels, pointed toed shoes
Most Common Problems:
      Bunions
      hammer toe
      claw toe
      ingrown nails
      metatarsalgia
      Morton’s neuroma’s
Other Common Problems:
      Hallux rigidus
      Stress fractures
Midfoot Problems:
Chronic dorsal pain
     Degenerative arthritis
         Pt will often be able to pinpoint the exact location of the pain
         Boney prominence (dorsal bossing) often can be palpated
Plantar pain is uncommon
     Plantar fasciitis or plantar fibromas

Hindfoot Problems:
Plantar heel pain most common
     Plantar fasciitis
              o Pt will report painful first steps in AM ;
              o Pt pain free at rest;
              o focal pain directly over plantar medial heel
     Posterior heel pain
              o irritation from shoes
              o prominent calcaneus (Haglund’s Deformity)
              o dystrophic changes of the Achilles tendon at its insertion
     Posterior tibial dysfunction is a commonly overlooked problem
              o Characterized by pain and tenderness posterior and distal to the medial malleolus in the
                  region of the posterior tibial tendon.
              o Progressive changes here can lead to acquired flat foot

Ankle Problems:
Acute Pain
     Sprains anterolateral pain, swelling and ecchymosis (frequently)
Chronic Pain:
     Instability anterolateral pain with intermittent episodes of giving way
     Low grade pain and swelling
             o peroneal tendon injuries
             o osteochondral lesions
             o subtalar arthritis/synovitis

                                         Fractures of the Ankle

Structures Affected Include:
Lateral malleolus
medial malleolus
posterior malleolus
collateral ligamentous structure
deltoid ligamentous structures
talar dome

Working Definitions of Fractures

Stable Ankle Fracture
Only one side of joint involved
Treat Symptomatically
Fibula only  weight bearing cast 4-6 weeks

Unstable Ankle Fracture
More than one side of joint affected;

Common Unstable Fractures of Ankle
    Bimalleolar (lateral and medial malleolus or distal fibula and deltoid ligament);
      Trimalleolar (involves posterior malleolus)
      Trimal with posterior dislocation  trimal fracture-dislocation
            o Vulnerable for displacement and posttraumatic arthritis
Treatment –
    Non-displaced
            o NWB long/short leg cast with prolonged immobilization
    Displaced
            o closed or open reduction
            o NWB long/short leg cast with prolonged immobilization
    Open fractures
            o surgical debridement

Clinical Presentation
Varied but usually involve some element of twisting or rotation

PE:
Swelling, tenderness, palpable gap, ecchymosis (often), ext. rotation and lateral displacement all common
Palpate all malleoli for tenderness, palpate the deltoid ligament; palpate the proximal fibula for tenderness
b/c when accompanied with medial swelling  Maisonneuve fracture (unstable ext rotation injury)
Access circulatory status and sensory status
Examine all lacerations as possible indications of an open fracture

Diagnostic tests:
X-ray – AP Lateral and mortise views, include proximal fibula if necessary
CT necessary in complex fractures

                              Fractures of the Calcaneus and Talus
Definition:
Calcaneus and talus fractures usually resulting from severe trauma
Seldom occur together
When both fractured usually involves the articular surfaces and are serious injuries

Symptoms:
Acute pain and inability to bear weight

PE:
Swelling, tenderness.
Access nerve functions of superficial peroneal (eversion), deep peroneal (foot drop, ↓dorsiflexion), sural,
medial and lateral plantar nerves distal to the fracture
Access circulatory status (DP, AT, PT) including cap refill of toes
Compartment syndrome is possible esp with notable swelling in the arch
Palpate the L-Spine tenderness  possible fracture

Diagnostic Tests:
X-ray
AP and Lateral of the hindfoot
AP and mortise of the ankle
AP and lateral L-Spine if tenderness
CT for complex fractures or further evaluation

Treatment:
Splinting with well padded posterior splint from toe to upper calf
Elevate extremity above the heart
Ice for 20 minutes q 1-2 hours
Surgical reduction and fixation often needed
Surgical debridement of open fracture



                                    Fractures of the Metatarsal
Working Definitions
Zones of Fracture (Essentials, p. 453)
Zone 1
Zone 2
Classic Jones Fracture
Fracture of proximal diaphysis of the 5th metatarsal
Requires more intentional immobilization
Zone 3
Can result in non-union or delayed union

Fractures of metatarsals usually heal with non-operative treatment except as noted

Clinical Symptoms
Pain with weight bearing and swelling common

PE:
Swelling , ecchymosis and tenderness over fracture site

Diagnostic Tests:
AP, lateral and oblique of foot
Treatment:
Non-displaced metatarsal neck and shaft fx
short leg cast, fracture brace or wooden soled shoe
Weight bearing as tolerated
Repeat x rays in one week to check displacement
Then in 6 weeks to confirm healing

Displaced Fractures with 4 mm displacement or 10° angulation
Closed or open reduction

5th metatarsal fractures may be easy or difficult to manage.
Easy to treat: Avulsion fractures of the fifth metatarsal base (zone 1) or proximal metaphyseal fractures
(zone 2) do well with non-operative treatment. Immobilize with fracture brace, wooden soled shoe until sx
subside
Difficult to treat: Acute fractures (Zone 2) NWB in short leg cast 6-8 weeks. Some (athletes) need early
internal fixation. Fractures in Zone 3 often resemble stress fractures  have problems with non-union

Fractures which require further evaluation:
Multiple fractures
Fractures with >4mm displacement or >10° of angulation
Fractures occurring in Zone 2 and 3
Displaced or comminuted fractures of 1st metatarsal
Open fractures  surgical intervention


                              Fractures/Dislocations of the MidFoot

Aka Lisfranc fracture / dislocation
Easy to miss
Traumatic disruptions of tarsometatarsal joints
2nd Metatarsal injury is critical since 2MT “keys” into the cuboid and stabilizes the midfoot

Clinical Symptoms
Sprain type sx
Pain localized to dorsum of midfoot
Swelling relatively mild

PE
Max tenderness and swelling over tarsometatarsal joint vs ankle ligaments
Stabilize hindfoot and rotate and/or abduct forefoot  Severe Pain in Lizfranc fx

Diagnostic Tests
AP Lat Obliques of foot (consider WB films)
Look for colinearity of medial aspect of mid cuniform with medical aspect of 2nd MT on AP
Look for colinearity of medial aspect of mid cuniform with medical aspect of 4th MT on Oblique
Compare with uninjuried foot

Treatment
Non-displaced – 6-8 weeks of NWB cast immobilization followed by rigid arch support for 3 months
Displacement – surgical intervention for stability

                                      Fractures of the Phalanges
Aka Broken toe
Most commonly 5th phalanges
Usually involves proximal phalanx
Usually caused by direct trauma

Symptoms
Pain; Swelling; Ecchymosis

PE:
Deformity; local boney tenderness; pain; swelling; ecchymosis

Tests:
AP X ray

Treatment:
Buddy taping (usually the toe medial to affected toe) with gauze placed b/w toes to absorb moisture and
avoid maceration
Closed or open reduction under anesthesia are rarely needed except in cases of severe angulation or
articular surface involvement



                             Stress Fractures of the Foot and Ankle
Aka March Fracture

Definition
Caused by repetitive overloading to fatigue
Increased level of activity or beginning a new type of activity – marching
Weakened bone conditions predispose patients to stress fractures (amenorrhea, osteopenia and overuse a
common triad)
Metatarsals a common site of stress fractures esp 2nd metatarsal but also navicular, calaneus and fibula
Symptoms
Insidious pain and swelling
Increased pain with WB and relieved with rest
Diffusely swollen dorsum in metatarsal fractures
Lateral swelling in fibula fractures

PE
Localized tenderness and concomitant swelling directly over fracture site
Ecchymosis appears occasionally

Diagnostic tests
Bone scan within 5 days is usually positive
X rays may be negative for up to 2 weeks post fracture but will show healing callus
after 3-4 weeks

Treatment
Reduced activity and protective footwear
Metatarsal fx stiff soled shoe, wooden soled shoe or removable short leg fracture brace
Calcaneal or fibular fractures benefit from 2-4 weeks of immobilization in short leg walking cast
Navicular and 5th MT fractures should be casted and NWB
5th MT often requires IF

                            Sprains and Strains of the Ankle and Foot

Aka inversion injury; high ankle sprain’ lateral collateral ligament tear

Definition

Usually results in an injury to the lateral ligaments of the ankle (Posterior tibiofibular ligament; Anterior
Talofibular ligament; Calcaneofibular ligament) or the Anterior tibiofibular ligament (high ankle sprain)
High ankle sprains increase recovery time
Deltoid ligaments (medially) are less common injuries

Symptoms

Pain over injured ligament, swelling; loss of function
Report a popping sound followed by immediate swelling and inability to walk  a more severe sprain
History of ankle sprains may indicate chronic ankle instability

PE
Ecchymosis and swelling around entire ankle joint not just lateral side
Tenderness on palpation over the anterior talofibular and calcaneofibular ligament
Palpate the lateral and medial malleolus and base of the 5th MT for crepitus or tenderness caused by
fracture
Pain in anterior tibiofibular ligament suggests high ankle sprain
      squeeze test – compress the tibia and fibula together at mid calf
      external rotation test – Dorsiflex the ankle and ext rotate the foot
      pain in region of distal tibiofibular junction (aka syndesmosis) is positive for high ankle sprain

Diagnostic Tests
Tenderness over the distal fibula, ankle joint, syndesmosis or other boney structure x rays are needed to
evaluate for fracture
Marked swelling and inability to bear weight are indications for x rays

Treatment:
Goal of treatment is to prevent chronic pain and instability
Phase 1 – NSAID’s, ice, compression, elevation, brace or air stirrup to promote soft tissue healing. WB as
tolerated, crutches as needed. 48° after injury contrast baths. Severe sprains may need cast or cast boot for 3
weeks to facilitate healing and walking
Phase 2 – begins when patient can bear weight w/o increased pain or swelling (usually 2-4 weeks). Begin
exercises to increase peroneal and dosiflexion strength, Achilles tendon stretching also. Continue until
patient has full ROM and 80% strength. (NO plantar flexion exercises since this position is the least stable
position of the ankle)
Phase 3 – usually begins 4-6 weeks after the injury. Begin functional conditioning: proprioception, agility
and endurance training.
         Proprioception – stand on injured ankle, elevate other foot, close eyes
         Agility and Endurance – running (walking) in progressively smaller Figure of 8 patterns
         strengthens peroneal muscles and adds to agility. Begin to wean patient off air stirrup or brace

Long term bracing may be indicated for the athlete involved in high risk ankle sprain sports – volleyball,
basketball and soccer.

Failure to improve indicates need for further evaluation.
Musculoskeletal System

Disorders of the Shoulder                    Disorders of Back/Spine              Infectious Diseases
Fractures/dislocations                       Ankylosing spondylitis               Acute/chronic osteomyelitis
Rotator cuff disorders                       Back strain/sprain                   Septic arthritis
Separations                                  Cauda equina                         Neoplastic Disease
Sprain/strain                                Herniated disk pulposis              Bone cysts/tumors
Disorders of the Forearm/Wrist/Hand          Kyphosis/scoliosis                   Ganglion cysts
Fractures/dislocations                       Low back pain                        Osteosarcoma
• Boxer's                                    Spinal stenosis                      Osteoarthritis
• Colles'                                    Disorders of the Hip                 Osteoporosis
• Gamekeeper's thumb                         Aseptic necrosis                     Rheumatologic Conditions
• Humeral                                    Fractures/dislocations               Fibromyalgia
• Nursemaid's elbow                          Slipped capital femoral epiphysis    Gout/pseudogout
• Scaphoid                                   Disorders of the Knee                Juvenile rheumatoid arthritis
Sprains/strains                              Bursitis                             Polyarteritis nodosa
Tenosynovitis                                Fractures/dislocations               Polymyositis
• Carpal tunnel syndrome                     Meniscal injuries                    Polymyalgia rheumatica
• de Quervain's tenosynovitis                Osgood-Schlatter disease             Reiter's syndrome
• Elbow tendinitis                           Sprains/strains                      Rheumatoid arthritis
• Epicondylitis                              Disorders of the Ankle/Foot          Systemic lupus erythematosus
                                             Fractures/dislocations               Scleroderma Sjogren's syndrome
                                             Sprains/strains

`

s
    % of Exam
     Content
                  Knowledge & Skill Areas                                 The tasks you’ll be
                                                                          tested on can be
        16
                  History Taking & Performing                             grouped into seven
                  Physical Examinations                                   categories. Click on the
        14
                  Using Laboratory &                                      category for a list of
                  Diagnostic Studies                                      tasks and evaluative
                                                                          objectives that will
                  Formulating Most Likely
        18                                                                help you gauge the
                  Diagnosis
                                                                          depth of knowledge
        14        Clinical Intervention                                   required.
        18        Clinical Therapeutics
        10        Health Maintenance
        10        Applying Scientific Concepts
    Total: 100%




1. History Taking & Performing Physical Examinations

Knowledge of:
• Etiologies associated with presenting symptoms or physical findings.
• Signs and symptoms of selected medical conditions.
• Risk factors for development of selected medical conditions.
• Pertinent historical information associated with selected medical conditions.
• Physical examination techniques.
• Physical examination of findings associated with selected medical conditions.
• Appropriate physical examination directed to selected medical conditions.


Skills in:
• Identification of pertinent historical information.
• Association of current complaint with presented history.
• Identification of pertinent physical examination information.


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2. Using Laboratory & Diagnostic Studies

Knowledge of:
• Indications for initial and subsequent diagnostic or laboratory studies.
• Cost effectiveness of diagnostic studies or procedures.
• Relevance of common screening tests for selected medical conditions
• Normal and abnormal diagnostic data.


Skills in:
• Selection of appropriate diagnostic or laboratory studies.
• Collection of diagnostic or laboratory specimens.
• Interpretation of diagnostic or laboratory studies results.
• Prediction or diagnostic or laboratory studies results.


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3. Formulating Most Likely Diagnosis

Knowledge of:
• Interpreting history as probable cause to differentiate disorders.
• Interpreting particular physical findings in order to differentiate disorders.
• Clinical implications and correlation of subjective and objective data.


Skills in:
• Correlation of normal and abnormal diagnostic data.
• Formulation of differential diagnosis.
• Selection of most likely diagnosis in light of presented data.


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4. Clinical Intervention

Tasks:
• Indications, contraindications, complications, and techniques for selected procedures.
• Management of selected medical conditions to exclude pharmacologic agents.
• Follow-up and monitoring of therapeutic regimens.
• Indication for admission to hospital or other facilities.
• Conditions that constitute medical emergencies.
• Discharge planning
• Available medical or surgical options
• Universal precautions
• Sterile technique
• Informed consent
• Surgical principles
• Wound healing
• Appropriate patient education regarding current condition and related risk factors.


Skills in:
• Formulating and implementing plans


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5. Clinical Therapeutics

Knowledge of:
• Pharmocokinetic properties of pharmacologic agents used in the treatment of
• selected conditions.
• Indications, contraindications, side effects, and adverse reactions of
• pharmacologic agents.
• Follow-up and monitoring of pharmacologic regimens.
• Risks for, clinical presentation of, and treatment of drug interactions.
• Risks for, clinical presentation of, and treatment of acute drug toxicity.
Skills in:
• Selection of appropriate pharmacologic therapy for selected medical conditions.


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6. Health Maintenance

Knowledge of:
• Epidemiology of selected medical conditions.
• Risk factors for conditions amenable to prevention or detection in an
• asymptomatic individual.
• Relative value of common screening tests for conditions amenable to prevention
• or detection in an asymptomatic individual.
• Appropriate patient education regarding preventable conditions or needed
• lifestyle modifications.
• Immunization schedules for infants, children, adults and foreign travelers.
• Behavioral change models.
• Stress adaptation and coping.


Skills in:
• Counseling and patient education techniques.


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7. Applying Scientific Concepts

Knowledge of:
• Underlying pathologic processes or pathways associated with a given condition.
• Normal and abnormal anatomy and physiology including human growth,
• development and sexuality.
• Normal and abnormal microbiology.

				
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