Conservative tmt 1st:(after 8 wks will be effective for 95% of pts)

- 1/4-1/2 inch heel lift (b/l)

- ice massage x 7-8 min

- NSAIDS

- Footwear

- wt. loss

- no barefoot walking

- achilles and plantar fascia stretches

- night splint (2nd line tmt b/c expensive)

If conservative fails: cortisone injection, PT, ortho referral if sx > 4 months

- syndesmosis: high sprain (5%) injury to the tibiofubular ligaments and interossceous membrane
Most common sprain: anterior talofibular, due to plantar flexion and inversion

Hx: Known twist of ankle,

ankle pain: pop/crack, edema, pain with ambulation

PMH of previous ankle injury 

• creates an abnormal space between the medial malleolus and talus
• this mechanism can also cause an avulsion fracture (occurs when the deltoid lig. tears off a piece of bone)

• tests lateral ankle instability (anterior talofibular ligament)
• if + will have anterior subluxation of ankle
• Grade 1: no laxity
• Grade 2: + laxity, firm end feel 
• Grade 3: significant laxity, soft end feel

1. Anterior drawer test: tests for anterior talofibular tear
2. Talar tilt test: tests for subtalar instability
3. Heel tab test: for fx
4. Tib/fib squeeze test: for fx

• If grade 2-3 sprain, tenderness of distal tibia/fibula/malleolus, or syndesmosis, or deformity is found = Xray
• grade 1 does not require Xray

-nerve injury

- peroneal tendon rupture

- chronic instability

- failure to improve in 6 weeks with appropriate tmt

To prevent chronic pain or instability

Phase 1:

I.C.E (ice, compression, elevation)

      WBAT

      Contrast

      Gentle ROM

NSAID after 48-72 hours

Brace

Phase 2: Strength *for athletes to be done by trainer

theraband/elastic

continue achilles stretching

Phase 3: Strength *for athletes to be done by trainer

agility

proprioception

endurance

Medial tibila stress syndrome

- "shin splints" tenderness on medial shin

- Tibialis posterior

- overuse syndrome, often with excessive pronation of the foot

- Clinical evaluation: tenderness extends along a considerable vertical distance behind the medial tibial border

- DDx: perisotitis, posterior tibial tendonitis, flexor muscles of the toes, stress fx

Tibial stress fractures

- Usually follow at least 3 weeks of training

- often with training on hard surface, overtraining, poor foot ware and frequent protonation of the foot

- pin point tenderness across a horizontal area of the tibia

- proximal, medial border of tibia and lower portion of fibula are most common areas

- Risk factors: new, different, or rigorous repetitive activity, female, increased age, caucasian, low bone mineral density, low calcium intake, (Very thin women)

- PE: local tenderness and edema

- Xray: may be negative initially, then show healing changes in -3 weeks

- bone scan more sensitive, do if suspect stress fx and plain films are neg

Causes: beginning runners, hard surfaces, heavy heel striking, inadequate foot ware, lack of stretching

DDx: Tibialis anterior strain, tibila stress fx, anterior compartment syndrome

1. stretching of lower extremity: hamstring, calf, tibialis posterior and anterior
2. Modify training to decrease lower leg stress
   • bike, change surface, correct foot ware and protonation, swim, PT, ice and NSAIDS

1. Refer to ortho
2. No running x 6-8 weeks (plus fain free running, Xray shows healing)
3. if nonunion occurs: cast

• Mech: stop and go action
• Hx of Achilles tendonitis
• Sudden snap, hear loud pop
• felt like hit with a bat in back of leg
• immediate pain which them subsides
• Strength: difficult/inability to do toe raise = ↓ achilles strength
• usually involve the avascular area 2.5-5 cm proximal to calcaneal insertion
• Causes: high energy disruption, degenerative changes, mechanical imbalance
• Risk factors: corticosteroid or quinolone use, chronic dz (DM, RA, SLE), poor footware

Inspection: edema diffuse at distal leg/ankle, +/- ecchymosis

Palpation: tenderness diffuse, palpable deviation/groove in gastrocnemius at junction or achilles tendon mass in mid calf

ROM: decreased 

Tests for continuity of the Achilles tendon

- pt on belly or with knee in flexion

- squeeze calf: absence or minimal foot-plantar flexion compared to the unaffected ankle indicates a rupture = + test

- false-neg: plantaris muscle or a Hematoma and inflammation that is present post-acutely can produce plantar flexion

- 20-25% of ruptures are missed by the 1st examiner

Treatment of Achilles rupture

• immediate ortho referral
• complete rupture: surgical repair
• Partial rupture: PT, casts, walker boot

- "pump bump", a bony prominence at back of heel, which can become callused or erythematous 
- can lead to retrocalcaneal bursitis 

- - incidious onset of dull pain at retrocalcaneal area

- often in pts younger than 30

- local pt tenderness at posterosuperior and lateral margins of calcaneus

- aggravated by footwear (tight shoes w/ constriction of heel)

Do standing A/P, lateral and oblique views

- seen as prominence or exotosis on posterosuperior border of calcaneal tuberosity on lateral view

- may see calcification within the achilles tendon on lateral or oblique views

Goal: ↓ friction of the bursa

- heel lift 

- open heel

NSAIDS, ice massage, stretching gastrocnemius

NO corticosterois (contraindicated around achilles b/c ↑ risk of rupture)

Ortho referral if conservative tmt fails

Conservative: 

- shoe modification (wide toed)

- felt pad proximal to metatarsal head

- corticosteroid injections

Surgical:

- surgical resection is indicated if above fails

Bunion

- deformity of the great toe

- characterized by adduction (medial deviation) of the metatarsal and lateral deviation of the hallux

- alone does not cause symptoms, the prominent metatarsal head (bunion and overlying bursa) become irritated

cause: heredity, constricting foot ware, pronated hindfood

Conservative: relieve P over boney prominence, well fitting low healed shoes, stretch the toe portion of shoes, extra depth shoes, splints between toes

Surgical: for disabling pain with deformity (excision of exotosis and realignment of the the toe)

- thick hard painful skin that develops 2nd to abnormal P on skin of foot

- Soft: in areas that are damp and moist, skin becomes macerated and clavus molvus develops (common between 4th and 5th toes)

- Hard: develop anywhere there is friction (most commonly found on dorsal side of PIP joint of 5th toe)

- Must be careful in DM patients: tell them never to cut a corm or callus themselves

avoid cutting

remove external P

low heeled shoes

adequate width

donut pads

warm soak and pumice stone

salicytic acid salve

lambs wool between soft corns

- mech of injury
- onset: acute vs chronic
- associated sx: crack, pop, crepitus, edema, ecchymosis
- description of pain
- response to tx
- any related PMH
- meds
- allergies (esp NSAIDs)
- review of baseline health (ulcer, bleeding dz, asthma, arthritis, OA)
- FH of OA

Exam: Gait or general movement of area

Inspection: Edema, effusion, ecchymosis, deformity, erythema

Palpitation: Pt tenderness, crepitus, local warmth, pops, cracks, palpable abnormalities

ROM

Strength

Special tests 

Neurovascular status

Diagnostic tests: Xray, CT, MRI, EMG, Bone scan, strength

• I.C.E. for 1st 24-72 hrs
• Contrast tmt after that: alternate 4 min of warm then 1 min of cold 4 times (for 20 min), then elevate x 10 minutes

Inflammation and pain at the proximal plantar fascia

- Exam: Pt tender with firm deep palpate at medial calcaneal tuberosity and proximal medial plantar fascia 

- Dx: hx and exam. Xray not necessary

- hx: morning pain, first few steps. Pain after sitting during 1st few steps. NWB relieves pain

• Mech: micro tearing in tendon or tendon sheath, with repeated trauma leading to chronic inflammation and tissue degeneration
• Exam: local edema, pt tender at achilles 2-6 cm form insertion
• crepitus 
• ↓ plantar flexion and strength

- commonly involves the plantar 3rd webspace

- insideous onset

- burning pain and numbness (later) in affected toes: worse with narrow shoes or elevated heels

- Special testing: Compression test

- squeeze metatarsal heads together x 30 sec