chapter 4 clinical assessment of foot & toe injuries part ii
TRANSCRIPT
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Chapter 4Clinical Assessment of
Foot & Toe Injuries
Part II
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Student Learning Outcomes
Identify common midfoot & forefoot injuries based on their presenting history, symptoms, visual signs (inspection), & palpation findings
Identify special tests that might be used to evaluate these injuries
Discuss basic management strategies for dealing with these injuries
Discuss anatomical or biomechanical predisposing factors associated with these common midfoot & forefoot injuries
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Location of Pain: Medial Calcaneus/Medial Arch
Injuries to consider (continued from Ch. 4 Part 1)
tarsal tunnel syndrome impingement &
inflammation of the posterior tibial nerve within the tarsal tunnel
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History
Tarsal tunnel syndrome Symptoms
pain, numbness, or parasthesia along medial or plantar aspectof foot
may mimic plantarfasciitis
Onset Acute or chronic
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History
Tarsal tunnel syndrome MOI
EV or PF/EV ankle injury (acute)
Forced PF (acute) Repetitive stress
associated with pesplanus foot
Previous history of tarsal fx
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History
Tarsal tunnel syndrome Possible related factors
Training surface Distance Shoes
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Inspection
Tarsal tunnel syndrome pes planus foot typically no swelling,
discoloration, or deformity
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Palpation
Tarsal tunnel syndrome Point tenderness
proximal, over, and distal to the flexorretinaculum
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ROM
Tarsal tunnel syndrome AROM
normal EV may reproduce
symptoms PROM
PF & EV may reproducesymptoms
RROM may demonstrate
weakness of toe flexors
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Stress Tests/Special Tests
Tarsal Tunnel Syndrome n/a
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Neurological Tests
Tarsal Tunnel Syndrome Tinel’s sign Decreased sensation
over nerve distribution
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Management
Tarsal Tunnel Syndrome Ice NSAIDs Orthotics Surgical release (in
severe cases)
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Location of Pain: Midfoot
Injuries to consider fx/dislocation sprain strain/inflammation of tendon
insertion sites tarsal coalition
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Location of Pain: Midfoot
Injuries to consider fx/dislocation
Lisfranc injury navicular stress fx
Lisfranc injury
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Location of Pain: Midfoot
Injuries to consider: sprain
midtarsal joints tarsometatarsal joints
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Location of Pain: Midfoot
Injuries to consider: strain/inflammation of muscle/tendon at
insertion sites tibialis posterior tibialis anterior peroneal longus peroneal brevis
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Location of Pain: Midfoot
Injuries to consider: Tarsal coalition
abnormal union between two or more tarsals bony fibrous Cartilaginous
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Location of Pain: Midfoot
Injuries to consider: Tarsal coalition
typically presents between 3 – 16 yrs of age 3 – 5 yrs: talonavicular coalition jt. 8 – 12 yrs: calcaneonavicular jt. 12 – 16 yrs: talocalcaneal jt.
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Location of Pain: Midfoot
Injuries to consider: Tarsal coalition
will present clinically as a rigid pes planus limitations in subtalar joint
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History
Location of pain
(midfoot)Symptoms Onset MOI
Fx/dislocationAcute; trauma
Dropping something on the foot; stepping in hole or on uneven ground - twisting the foot
Lisfranc fx**Acute; trauma
Dropping something on the foot; stepping in hole or on uneven ground - twisting the foot**
SprainAcute; trauma
Twisting the foot
Strain/inflammation of tendon insertion site(s)
Acute or chronic
Forceful contraction; repetitive stress
Tarsal coalition congenital n/a
**often mistaken for midfoot sprain
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Inspection/Observation
Location of pain
(midfoot)
Signs
Deformity? Swelling? Discoloration?
Fx/dislocationPossible Possible Possible
Lisfranc fx Possible Common Possible
Sprain No Common Possible
Strain/inflammation of tendon insertion site(s) No Minimal if at all Typically not
Tarsal coalition
Rigid pes planus; ABD of forefoot,
medial displacement of talus; navicular
drop
No No
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Palpation
Location of pain
(midfoot)
Point tenderness? Deformity? Swelling? Crepitus?
Fx/dislocationDirectly over
1 or more tarsals
Possible Possible Possible
SprainOver
involved joint
No Possible Possible
Strain/inflammation of tendon insertion site(s)
Over tendon or insertion
site
Usually notPossible, would be minimal
Possible
Tarsal coalitionOver
involved joint
Typically notTypically
notNo
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Physical Exam
Location of pain
(midfoot)ROM? Stress Tests?
Special Tests?
Neurological?
Fx/dislocation n/a n/a n/a n/a
Sprain n/a
Intermetatarsal glide test
Midtarsal joint glides
Tarsometatarsal joint glides
n/an/a
Strain/inflammation of tendon insertion site(s) n/a n/a
Pain w/passive stretching of muscle/tendon;
Pain w/resisted action of muscle tendon
n/a
Tarsal coalitionMay have
limitation in IN/EV
n/a n/a n/a
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Management
Midfoot fx/dislocations Ice Walking boot or NWB Spring steel innersole Surgery (when severely displaced)
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Management
Lisfranc fx/dislocation Cast NWB Rigid orthotic Surgery when necessary to
stabilize
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Management
Midfoot sprain Ice NSAIDs Spring steel innersole or rigid
orthotic Strengthening of intrinsic foot
muscles
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Management
Inflammation at tendon insertion sites Ice NSAIDs Stretching Strengthening of involved muscle
with emphasis on eccentrics
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Management
Tarsal coalition referral to orthopedist
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Location of Pain: Forefoot
Injuries to consider Fx
midshaft avulsion Jones’ fx
Intermetatarsal (Morton’s)neuroma
metatarsalgia
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History
Location of pain
(forefoot) Symptoms Onset MOI
Midshaft fxPain directly over
metatarsal
Acute or chronic
(stress fx)
Acute: Getting stepped on or having something dropped onto MT; stepping in hole or onto uneven surface;
Chronic: repetitive stress, weakness of toe flexors
Avulsion fx
Most common site: styloid process of 5th MT
Pain over fracture site; may have heard/felt pop
AcuteBase of 5th MT: forceful contraction of peroneal
brevis
Jones’ fxPain over distal styloid of
5th metatarsalAcute
Force inversion with ankle in PF; landing on lateral
aspect of foot
Morton’s neuroma Pain, burning
Metatarsalgia Pain under head(s) of
metatarsals; may feel like “stepping on pebble”
Acute/chronic
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Inspection/Observation
Location of pain
(forefoot)
Signs
Deformity? Swelling? Discoloration?
Midshaft fx Avulsion fx Jones’ fx
Morton’s neuroma -- Possible --
Metatarsalgia -- Possible --
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Palpation
Location of pain
(forefoot)
Point tenderness? Deformity? Swelling? Crepitus?
Midshaft fx Avulsion fx Jones’ fx
Morton’s neuromaOver
neuroman/a n/a n/a
Metatarsalgia Over head of involved MT
Involved head may feel lower
than others
Minimal if present
n/a
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Physical Exam
Location of pain
(forefoot)ROM?
Stress Tests?
Special Tests?Neurological
?
Midshaft fxToe flex/ext may increase pain
--Tap test; Morton’s
test --
Avulsion fx
May have limitation if motion stresses fx site
-- -- --
Jones’ fxMay be limited in EV -- Morton’s test --
Morton’s neuromaToe ext. may increase symptoms
-- Morton’s test --
MetatarsalgiaToe ext. may increase symptoms
-- -- --
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Management
Midshaft fx/dislocation Ice NSAIDs Boot/cast Spring steel innersole Surgery with comminuted or
displaced fx
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Management
avulsion fx Boot/cast Surgery when necessary to
stabilize
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Management
Jones’ fx Boot/cast – NWB
Known for nonunions Surgery when necessary to
stabilize
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History
Location of pain Forefoot
between metatarsals neuroma intrinsic muscles
Symptoms•Burning pain•Electric shock•Dull ache
MOI•Gradual onset•Improper shoes•Forceful contraction•Stretching beyond normal limits of ROM
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Inspection/Palpation
Forefoot injuries between metatarsals
neuroma intrinsic muscles
Signs•swelling?
Palpation•Point tenderness•Compression of neuroma reproduces pain
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Stress/Special Tests
Forefoot injuries between metatarsals
neuroma intrinsic muscles
Tests•Morton’s Test•Abd/add of toes
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Management
Forefoot injuries between metatarsals
neuroma intrinsic muscles
Treatment•Ice•Anti-inflammatories•Orthotics
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Questions?